KMK No. 440 TTG Tarif RS Berdasarkan INA-CBG

KEPUTUSAN MENTERI KESEHATAN REPUBLIK INDONESIA
NOMOR 440/MENKES/SK/XII/2012
TENTANG
TARIF RUMAH SAKIT BERDASARKAN
INDONESIA CASE BASED GROUP (INA-CBG)
DENGAN RAHMAT TUHAN YANG MAHA ESA
MENTERI KESEHATAN REPUBLIK INDONESIA,
Menimbang
: a. bahwa dalam rangka meningkatkan mutu pelayanan

rumah sakit perlu adanya system pembayaran yang
efektif dan efisien;
b. bahwa tarif yang digunakan sebagai dasar klaim
Jamkesmas untuk rumah sakit pelaksana pelayanan
Jamkesmas saat ini adalah tarif yang ditetapkan
berdasarkan Keputusan Menteri Kesehatan Nomor
1161/MenKes/SK/X/2007 tentang Penetapan Tarif
Rumah Sakit Berdasarkan Indonesia Diagnosis
(INA-DRG) yang berasal dari data tahun 2006,
sehingga perlu dilakukan penyesuaian;
c.
Mengingat
bahwa berdasarkan pertimbangan sebagaimana

dimaksud huruf a dan huruf b diatas, perlu
menetapkan tarif rumah sakit berdasarkan Indonesia
Case Based Group (INA-CBG) dengan Keputusan
Menteri;
: 1. Undang-undang Nomor 36 tahun 2009 tentang

Kesehatan (Lembaran Negara Republik Indonesia
tahun 2009 Nomor 144, Tambahan Lembaran Negara
Republik Indonesia Nomor 5063);
2. Undang-Undang Nomor 44 tahun 2009 tentang
Rumah Sakit (Lembaran Negara Republik Indonesia
tahun 2009 Nomor 153, Tambahan Lembaran Negara
Republik Indonesia Nomor 5072);
3. Undang-Undang Nomor 40 tahun 2004 tentang
Sistem Jaminan Sosial Nasional (Lembaran Negara
Republik Indonesia tahun 2009 Nomor 150,
Tambahan Lembaran Negara Republik Indonesia
Nomor 4456);
4. Peraturan
Menteri
Kesehatan
Nomor
1144/Menkes/PER/VIII/2010 tentang Organisasi
dan Tata Kerja Kementerian Kesehatan (Berita
Negara Republik Indonesia Tahun 2010 Nomor 585);
5. Peraturan .
-25. Peraturan
Menteri
Kesehatan
Nomor
1171/MENKES/PER/VI/2011
tentang
Sistem
Informasi Rumah Sakit (Berita Negara Republik
Indonesia Tahun 2011 Nomor 378);
MEMUTUSKAN
Menetapkan
: KEPUTUSAN MENTERI KESEHATAN TENTANG TARIF

RUMAH SAKIT BERDASARKAN INDONESIA CASE BASED
GROUP (INA-CBG).
KESATU
: Tarif Rumah Sakit berdasarkan Indonesia Case Based

Groups (INA-CBG) yang selanjutnya disebut tarif INACBG terbagi menjadi 4 (empat) regional, yang terdiriatas:
1. Regional 1 untuk daerah Jawa, danBali;
2. Regional 2 untuk daerah Sumatera;
3. Regional 3 untuk daerah Kalimantan, Sulawesi, dan
Nusa Tenggara Barat (NTB); dan
4. Regional 4 untuk daerah Nusa Tenggara Timur (NTT),
Maluku, Maluku Utara,Papua, danPapua Barat.
KEDUA
: Tarif INA-CBG dalam setiap regional sebagaimana

dimaksud pada Diktum Kesatu dikelompokkan menurut
tipe dan kelas rumah sakit, yang terdiri dari:
1. Tarif INA-CBG Rumah Sakit Umum dan Khusus
Kelas A Tahun 2012;
Kelas B Pendidikan Tahun 2012;
Kelas B Non Pendidikan Tahun 2012;
Kelas C Tahun 2012;
Kelas D Tahun 2012;
6. Tarif INA-CBG Rumah Sakit Umum Pusat Nasional
Dr. Cipto Mangunkusumo Tahun 2012;
7. Tarif INA-CBG Rumah Sakit Anak dan Bunda
Harapan Kita Tahun 2012;
8. Tarif INA-CBG Rumah Sakit Jantung dan Pembuluh
Darah Harapan Kita Tahun 2012;
9. Tarif INA-CBG Rumah Sakit Kanker Dharmais Tahun
2012;
10. Tarif
-310. Tarif INA-CBG Rumah Sakit Khusus Stroke Nasional

Bukittinggi Tahun 2012;
11. Tarif INA-CBG Rumah Sakit Ketergantungan Obat
Jakarta Tahun 2012; dan
12. Tarif INA-CBG Rumah Sakit Penyakit Infeksi Prof. Dr.
Sulianti Saroso Tahun 2012.
KETIGA
: Daftar Tarif INA-CBG sebagaimana dimaksud pada

Diktum Kedua tercantum dalam Lampiran yang
merupakan bagian yang tidak terpisahkan dari
Peraturan Menteri ini.
KEEMPAT
: Tarif INA-CBG sebagaimana dimaksud pada Diktum

Ketiga merupakan tarif pelayanan kesehatan di ruang
perawatan Kelas III Rumah Sakit yang berlaku Untuk
Rumah Sakit Umum dan Rumah Sakit Khusus milik
pemerintah dan swasta yang bekerja sama dalam
program Jamkesmas.
KELIMA
: Tarif INA-CBG sebagaimana dimaksud pada Diktum

Ketiga
dapat
digunakan
sebagai
acuan
dalam
menentukan besaran tarif rumah sakit.
KEENAM
: Pada saat Keputusan ini mulai berlaku, Keputusan

Menteri Kesehatan Nomor 1161/MenKes/SK/X/2007
tentang Penetapan tarif rumah sakit Berdasarkan
Indonesia Diagnosis Related Groups(INA-DRG) dicabut
dan dinyatakan tidak berlaku lagi.
KETUJUH
: Keputusan ini berlaku mulai tanggal 01 Januari 2013.

Ditetapkan di Jakarta
pada tanggal 27 Desember 2012
MENTERI KESEHATAN
REPUBLIK INDONESIA,
ttd
NAFSIAH MBOI
LAMPIRAN
KEPUTUSAN MENTERI KESEHATAN
NOMOR 440/MENKES/SK/XII/2012
TENTANG
TARIF RUMAH SAKIT BERDASARKAN
INDONESIA CASE BASED GROUP
(INA-CBG)
DAFTAR TARIF RUMAH SAKIT BERDASARKAN
INDONESIA CASE BASED GROUP (INA-CBG)
I.
TARIF INA-CBG RUMAH SAKIT UMUM DAN KHUSUS KELAS A

TAHUN 2012
A. TARIF INA-CBG RUMAH SAKIT UMUM KELAS A
1. RawatInap
No
Kode
INA-CBG
A-4-10-i
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
SEPTIKEMIA RINGAN
2,408,346
2,430,021
2,444,471
2,458,921
A-4-10-ii
SEPTIKEMIA SEDANG
4,116,079
4,153,124
4,177,820
4,202,517
A-4-10-iii
SEPTIKEMIA BERAT
7.154.169
7.218.556
7.261.481
7.304.406
A-4-11-i
INFEKSI SESUDAH OPERASI & TRAUMA RINGAN
6.462.263
6.520.424
6.559.197
6.597.971
A-4-11-ii
INFEKSI SESUDAH OPERASI & TRAUMA SEDANG
9.983.450
10.073.301
10.133.202
10.193.103
A-4-11-iii
INFEKSI SESUDAH OPERASI & TRAUMA BERAT
16.330.743
16.477.720
16.575.705
16.673.689
A-4-12-i
DEMAM RINGAN
2.810.382
2.835.675
2.852.538
2.869.400
A-4-12-ii
DEMAM SEDANG
3.635.957
3.668.680
3.690.496
3.712.312
A-4-12-iii
DEMAM BERAT
4.288.246
4.326.841
4.352.570
4.378.300
10
A-4-13-i
INFEKSI NON BAKTERI RINGAN
3.512.977
3.544.594
3.565.672
3.586.750
11
A-4-13-ii
INFEKSI NON BAKTERI SEDANG
3.983.203
4.019.052
4.042.951
4.066.850
12
A-4-13-iii
INFEKSI NON BAKTERI BERAT
5.008.213
5.053.287
5.083.336
5.113.385
2.810.382
2.835.675
2.852.538
2.869.400
3.616.450
3.648.998
3.670.697
3.692.395
4.132.158
4.169.348
4.194.141
4.218.934
PENYAKIT INFEKSI BAKTERI DAN PARASIT

LAIN-LAIN RINGAN
LAIN-LAIN SEDANG
LAIN-LAIN BERAT
13
A-4-14-i
14
A-4-14-ii
15
A-4-14-iii
16
A-4-15-i
INFEKSI HIV RINGAN
4.215.573
4.253.513
4.278.806
4.304.100
17
A-4-15-ii
INFEKSI HIV SEDANG
6.323.359
6.380.270
6.418.210
6.456.150
18
A-4-15-iii
INFEKSI HIV BERAT
7.932.677
8.004.071
8.051.667
8.099.263
19
B-1-01-i
PROSEDUR PENCANGKOKAN HATI RINGAN
46.736.197
47.156.823
47.437.240
47.717.657
20
B-1-01-ii
PROSEDUR PENCANGKOKAN HATI SEDANG
51.562.521
52.026.583
52.335.958
52.645.334
-2No
Kode
INA-CBG
21
B-1-01-iii
22
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
PROSEDUR PENCANGKOKAN HATI BERAT
90.451.272
91.265.333
91.808.041
92.350.748
B-1-10-i
PROSEDUR HATI DAN PANKREAS RINGAN
6.059.189
6.113.722
6.150.077
6.186.432
23
B-1-10-ii
PROSEDUR HATI DAN PANKREAS SEDANG
15.441.733
15.580.709
15.673.359
15.766.009
24
B-1-10-iii
PROSEDUR HATI DAN PANKREAS BERAT
24.244.567
24.462.768
24.608.235
24.753.703
3.736.409
3.770.036
3.792.455
3.814.873
9.378.739
9.463.147
9.519.420
9.575.692
11.758.611
11.864.438
11.934.990
12.005.541
7.969.895
8.041.624
8.089.443
8.137.262
17.081.434
17.235.166
17.337.655
17.440.144
20.788.748
20.975.847
21.100.580
21.225.312
5.222.495
5.269.497
5.300.832
5.332.167
8.506.686
8.583.246
8.634.286
8.685.326
12.541.242
12.654.113
12.729.360
12.804.608
7.091.780
7.155.606
7.198.157
7.240.707
7.887.491
7.958.478
8.005.803
8.053.128
12.339.041
12.450.093
12.524.127
12.598.161
PROSEDUR SALURAN EMPEDU KOMPLEK

(RINGAN)
(SEDANG)
(BERAT)
PROSEDUR CHOLESISTEKTOMI TANPA
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT
PROSEDUR PANKREAS DAN HEPATOBILLIARI
LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
PROSEDUR CHOLESISTEKTOMI DENGAN
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT
25
B-1-11-i
26
B-1-11-ii
27
B-1-11-iii
28
B-1-12-i
29
B-1-12-ii
30
B-1-12-iii
31
B-1-13-i
32
B-1-13-ii
33
B-1-13-iii
34
B-1-14-i
35
B-1-14-ii
36
B-1-14-iii
37
B-4-10-i
SIROSIS DAN HEPATITIS ALKOHOLIK RINGAN
2.198.762
2.218.551
2.231.744
2.244.936
38
B-4-10-ii
SIROSIS DAN HEPATITIS ALKOHOLIK SEDANG
3.512.977
3.544.594
3.565.672
3.586.750
39
B-4-10-iii
SIROSIS DAN HEPATITIS ALKOHOLIK BERAT
4.844.706
4.888.309
4.917.377
4.946.445
4.790.535
4.833.650
4.862.393
4.891.137
7.282.810
7.348.355
7.392.052
7.435.749
7.843.839
7.914.434
7.961.497
8.008.560
4.203.366
4.241.197
4.266.417
4.291.637
5.959.339
6.012.973
6.048.729
6.084.486
12.840.573
12.956.138
13.033.182
13.110.225
4.215.573
4.253.513
4.278.806
4.304.100
4.918.168
4.962.432
4.991.941
5.021.450
8.882.772
8.962.716
9.016.013
9.069.310
4.215.573
4.253.513
4.278.806
4.304.100
4.918.168
4.962.432
4.991.941
5.021.450
6.561.331
6.620.383
6.659.751
6.699.119
3.702.916
3.736.242
3.758.460
3.780.677
40
B-4-11-i
41
B-4-11-ii
42
B-4-11-iii
43
B-4-12-i
44
B-4-12-ii
45
B-4-12-iii
46
B-4-13-i
47
B-4-13-ii
48
B-4-13-iii
49
B-4-14-i
50
B-4-14-ii
51
B-4-14-iii
52
C-4-10-i
TUMOR SISTEM HEPATOBILLIARI DAN

PANCREAS RINGAN
PANCREAS SEDANG
PANCREAS BERAT
GANGGUAN PANKREAS SELAIN TUMOR
(RINGAN)
(SEDANG)
(BERAT)
GANGGUAN HATI SELAIN TUMOR, SIROSIS
ATAU HEPATITIS ALKOHOLIK RINGAN
ATAU HEPATITIS ALKOHOLIK SEDANG
ATAU HEPATITIS ALKOHOLIK BERAT
GANGGUAN SALURAN EMPEDU LAIN-LAIN
RINGAN
SEDANG
BERAT
LEUKEMIA AKUT RINGAN
-3No
Kode
INA-CBG
53
C-4-10-ii
LEUKEMIA AKUT SEDANG
54
C-4-10-iii
LEUKEMIA AKUT BERAT
55
C-4-11-i
56
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
7.728.550
7.798.107
7.844.479
7.890.850
13.349.314
13.469.458
13.549.554
13.629.650
LIMFOMA & LEUKEMIA NON AKUT RINGAN
4.215.573
4.253.513
4.278.806
4.304.100
C-4-11-ii
LIMFOMA & LEUKEMIA NON AKUT SEDANG
5.620.764
5.671.351
5.705.075
5.738.800
57
C-4-11-iii
LIMFOMA & LEUKEMIA NON AKUT BERAT
8.782.443
8.861.485
8.914.180
8.966.875
58
C-4-12-i
RADIOTERAPI RINGAN
2.810.382
2.835.675
2.852.538
2.869.400
59
C-4-12-ii
RADIOTERAPI SEDANG
6.979.712
7.042.529
7.084.408
7.126.286
60
C-4-12-iii
RADIOTERAPI BERAT
14.170.214
14.297.746
14.382.767
14.467.789
61
C-4-13-i
KEMOTERAPI RINGAN
2.737.046
2.761.680
2.778.102
2.794.524
62
C-4-13-ii
KEMOTERAPI SEDANG
5.139.337
5.185.591
5.216.427
5.247.263
63
C-4-13-iii
KEMOTERAPI BERAT
7.096.417
7.160.285
7.202.863
7.245.442
64
C-4-14-i
3.512.977
3.544.594
3.565.672
3.586.750
65
C-4-14-ii
4.918.168
4.962.432
4.991.941
5.021.450
66
C-4-14-iii
7.322.880
7.388.786
7.432.723
7.476.660
67
D-1-10-i
29.905.797
30.174.949
30.354.384
30.533.818
68
D-1-10-ii
45.548.822
45.958.762
46.232.055
46.505.348
69
D-1-10-iii
61.731.100
62.286.680
62.657.067
63.027.453
70
D-1-11-i
PROSEDUR LIMPA RINGAN
5.678.744
5.729.853
5.763.926
5.797.998
71
D-1-11-ii
PROSEDUR LIMPA SEDANG
14.461.428
14.591.580
14.678.349
14.765.118
72
D-1-11-iii
PROSEDUR LIMPA BERAT
22.714.978
22.919.413
23.055.703
23.191.992
73
D-1-20-i
7.571.659
7.639.804
7.685.234
7.730.664
74
D-1-20-ii
17.036.233
17.189.560
17.291.777
17.393.994
75
D-1-20-iii
27.778.577
28.028.584
28.195.256
28.361.927
76
D-4-10-i
AGRANULOSITOSIS RINGAN
2.699.544
2.723.840
2.740.038
2.756.235
77
D-4-10-ii
AGRANULOSITOSIS SEDANG
5.418.196
5.466.960
5.499.469
5.531.979
78
D-4-10-iii
AGRANULOSITOSIS BERAT
7.025.955
7.089.188
7.131.344
7.173.500
79
D-4-11-i
GANGGUAN PEMBEKUAN DARAH RINGAN
6.009.625
6.063.712
6.099.769
6.135.827
80
D-4-11-ii
GANGGUAN PEMBEKUAN DARAH SEDANG
10.849.527
10.947.173
11.012.270
11.077.367
81
D-4-11-iii
GANGGUAN PEMBEKUAN DARAH BERAT
14.904.614
15.038.756
15.128.184
15.217.611
82
D-4-12-i
KRISIS ANEMIA SEL SICKLE RINGAN
3.603.645
3.636.077
3.657.699
3.679.321
83
D-4-12-ii
KRISIS ANEMIA SEL SICKLE SEDANG
4.998.609
5.043.597
5.073.588
5.103.580
84
D-4-12-iii
KRISIS ANEMIA SEL SICKLE BERAT
7.675.367
7.744.445
7.790.498
7.836.550
85
D-4-13-i
GANGGUAN SEL DARAH MERAH SELAIN

2.724.084
2.748.601
2.764.946
2.781.290
TUMOR MYELOPROLIFERATIF LAIN-LAIN

RINGAN
SEDANG
BERAT
PROSEDUR PENCANGKOKAN SUMSUM
TULANG RINGAN
TULANG SEDANG
TULANG BERAT
PROSEDUR PADA DARAH DAN ORGAN

PEMBENTUK DARAH LAIN-LAIN (RINGAN)
PEMBENTUK DARAH LAIN-LAIN (SEDANG)
PEMBENTUK DARAH LAIN-LAIN (BERAT)
-4No
Kode
INA-CBG
86
D-4-13-ii
87
D-4-13-iii
88
D-4-14-i
89
D-4-14-ii
90
D-4-14-iii
91
E-1-01-i
92
E-1-01-ii
93
E-1-01-iii
94
E-1-10-i
95
E-1-10-ii
96
E-1-10-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.847.405
3.882.032
3.905.116
3.928.200
4.918.168
4.962.432
4.991.941
5.021.450
3.054.406
3.081.896
3.100.222
3.118.549
7.905.873
7.977.026
8.024.461
8.071.896
9.430.612
9.515.488
9.572.071
9.628.655
6.076.743
6.131.434
6.167.894
6.204.354
8.459.006
8.535.137
8.585.891
8.636.645
20.001.034
20.181.043
20.301.049
20.421.056
PROSEDUR KELENJAR ADRENAL RINGAN
6.864.421
6.926.200
6.967.387
7.008.573
PROSEDUR KELENJAR ADRENAL SEDANG
8.331.795
8.406.782
8.456.772
8.506.763
17.560.972
17.719.021
17.824.387
17.929.752
7.170.320
7.234.853
7.277.875
7.320.897
9.603.485
9.689.917
9.747.538
9.805.159
21.278.610
21.470.117
21.597.789
21.725.460
3.512.977
3.544.594
3.565.672
3.586.750
4.918.168
4.962.432
4.991.941
5.021.450
9.550.125
9.636.076
9.693.377
9.750.678
2.810.382
2.835.675
2.852.538
2.869.400
5.114.826
5.160.860
5.191.549
5.222.238
9.116.665
9.198.715
9.253.415
9.308.115

GANGGUAN PADA DARAH & ORGAN
PROSEDUR KELENJAR PITUITARI DAN PINEAL
RINGAN
SEDANG
BERAT
PROSEDUR KELENJAR ADRENAL BERAT

PROSEDUR PADA TIROID, PARATIROID DAN
SALURAN TIROGLOSAL RINGAN
SALURAN TIROGLOSAL SEDANG
SALURAN TIROGLOSAL BERAT
PENYAKIT KENCING MANIS & GANGGUAN
NUTRISI/ METABOLIK RINGAN
NUTRISI/ METABOLIK SEDANG
NUTRISI/ METABOLIK BERAT
HIPOVOLEMIA & GANGGUAN ELEKROLIT
RINGAN
SEDANG
BERAT
97
E-1-20-i
98
E-1-20-ii
99
E-1-20-iii
100
E-4-10-i
101
E-4-10-ii
102
E-4-10-iii
103
E-4-11-i
104
E-4-11-ii
105
E-4-11-iii
106
E-4-12-i
GANGGUAN METABOLIK BAWAAN RINGAN
3.230.474
3.259.549
3.278.931
3.298.314
107
E-4-12-ii
GANGGUAN METABOLIK BAWAAN SEDANG
5.611.943
5.662.450
5.696.122
5.729.794
108
E-4-12-iii
GANGGUAN METABOLIK BAWAAN BERAT
9.942.324
10.031.805
10.091.459
10.151.113
109
E-4-13-i
3.512.977
3.544.594
3.565.672
3.586.750
110
E-4-13-ii
5.850.733
5.903.389
5.938.494
5.973.598
111
E-4-13-iii
10.123.245
10.214.354
10.275.094
10.335.833
112
F-4-10-i
SCHIZOFRENIA RINGAN
4.166.336
4.203.833
4.228.831
4.253.829
113
F-4-10-ii
SCHIZOFRENIA SEDANG
4.626.850
4.668.491
4.696.252
4.724.013
114
F-4-10-iii
SCHIZOFRENIA BERAT
6.850.153
6.911.804
6.952.905
6.994.006
115
F-4-11-i
DEPRESI MAYOR RINGAN
3.840.352
3.874.915
3.897.957
3.921.000
116
F-4-11-ii
DEPRESI MAYOR SEDANG
4.474.375
4.514.644
4.541.491
4.568.337
117
F-4-11-iii
DEPRESI MAYOR BERAT
5.737.784
5.789.424
5.823.851
5.858.277
GANGGUAN KELENJAR ENDOKRIN LAIN-LAIN

RINGAN
SEDANG
BERAT
-5No
Kode
INA-CBG
118
F-4-12-i
119
F-4-12-ii
120
F-4-12-iii
121
F-4-13-i
122
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.107.786
2.126.757
2.139.403
2.152.050
3.009.620
3.036.707
3.054.764
3.072.822
6.528.866
6.587.626
6.626.799
6.665.972
GANGGUAN BIPOLAR RINGAN
3.103.588
3.131.520
3.150.142
3.168.763
F-4-13-ii
GANGGUAN BIPOLAR SEDANG
4.109.948
4.146.938
4.171.597
4.196.257
123
F-4-13-iii
GANGGUAN BIPOLAR BERAT
5.299.253
5.346.947
5.378.742
5.410.538
124
F-4-14-i
DEPRESI RINGAN
2.172.512
2.192.064
2.205.100
2.218.135
125
F-4-14-ii
DEPRESI SEDANG
2.786.687
2.811.767
2.828.487
2.845.207
126
F-4-14-iii
DEPRESI BERAT
3.749.611
3.783.358
3.805.856
3.828.353
127
F-4-15-i
NEUROSA SELAIN DEPRESI RINGAN
2.810.382
2.835.675
2.852.538
2.869.400
128
F-4-15-ii
NEUROSA SELAIN DEPRESI SEDANG
4.215.573
4.253.513
4.278.806
4.304.100
129
F-4-15-iii
NEUROSA SELAIN DEPRESI BERAT
5.552.168
5.602.138
5.635.451
5.668.764
130
F-4-16-i
5.563.261
5.613.330
5.646.710
5.680.089
131
F-4-16-ii
6.467.152
6.525.356
6.564.159
6.602.962
132
F-4-16-iii
8.632.568
8.710.261
8.762.056
8.813.852
133
F-4-17-i
1.424.009
1.436.825
1.445.369
1.453.913
134
F-4-17-ii
4.173.635
4.211.198
4.236.240
4.261.281
135
F-4-17-iii
4.452.962
4.493.038
4.519.756
4.546.474
136
F-4-18-i
GANGGUAN NUTRISI KOMPULSIF RINGAN
4.822.047
4.865.446
4.894.378
4.923.310
137
F-4-18-ii
GANGGUAN NUTRISI KOMPULSIF SEDANG
5.305.614
5.353.364
5.385.198
5.417.032
138
F-4-18-iii
GANGGUAN NUTRISI KOMPULSIF BERAT
8.179.066
8.252.678
8.301.752
8.350.826
139
F-4-19-i
GANGGUAN MENTAL LAIN-LAIN RINGAN
3.698.055
3.731.338
3.753.526
3.775.714
140
F-4-19-ii
GANGGUAN MENTAL LAIN-LAIN SEDANG
4.735.455
4.778.074
4.806.487
4.834.899
141
F-4-19-iii
GANGGUAN MENTAL LAIN-LAIN BERAT
5.895.704
5.948.766
5.984.140
6.019.514
142
G-1-01-i
13.033.910
13.151.215
13.229.419
13.307.622
143
G-1-01-ii
22.061.464
22.260.017
22.392.386
22.524.754
144
G-1-01-iii
42.708.530
43.092.907
43.349.158
43.605.409
145
G-1-10-i
PROSEDUR KRANIOTOMI RINGAN
14.400.000
14.529.600
14.616.000
14.702.400
146
G-1-10-ii
PROSEDUR KRANIOTOMI SEDANG
16.010.576
16.154.671
16.250.735
16.346.798
147
G-1-10-iii
PROSEDUR KRANIOTOMI BERAT
17.033.345
17.186.645
17.288.845
17.391.045
148
G-1-11-i
PROSEDUR VENTRICULAR SHUNT RINGAN
6.768.093
6.829.006
6.869.615
6.910.223
149
G-1-11-ii
PROSEDUR VENTRICULAR SHUNT SEDANG
13.898.790
14.023.879
14.107.271
14.190.664
150
G-1-11-iii
PROSEDUR VENTRICULAR SHUNT BERAT
29.102.802
29.364.727
29.539.344
29.713.960
GANGGUAN PERSONALITI & KONTROL

IMPULSE RINGAN
IMPULSE SEDANG
IMPULSE BERAT
GANGGUAN ORGANIK DAN

KETERBELAKANGAN MENTAL RINGAN
KETERBELAKANGAN MENTAL SEDANG
KETERBELAKANGAN MENTAL BERAT
GANGGUAN MENTAL PADA KANAK-KANAK
RINGAN
SEDANG
BERAT
PROSEDUR PADA PEMBULUH DARAH INTRA

KRANIAL RINGAN
PROSEDUR PEMBULUH DARAH INTRA
KRANIAL SEDANG
KRANIAL BERAT
-6No
Kode
INA-CBG
151
G-1-12-i
152
G-1-12-ii
153
G-1-12-iii
154
G-1-13-i
155
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.678.744
5.729.853
5.763.926
5.797.998
12.050.448
12.158.902
12.231.205
12.303.507
21.254.348
21.445.637
21.573.163
21.700.689
PROSEDUR CARPAL TUNNEL RELEASE RINGAN
1.538.951
1.552.801
1.562.035
1.571.269
G-1-13-ii
PROSEDUR CARPAL TUNNEL RELEASE SEDANG
4.133.451
4.170.652
4.195.453
4.220.254
156
G-1-13-iii
PROSEDUR CARPAL TUNNEL RELEASE BERAT
9.326.807
9.410.748
9.466.709
9.522.670
157
G-1-20-i
6.632.562
6.692.255
6.732.050
6.771.845
158
G-1-20-ii
8.960.808
9.041.456
9.095.220
9.148.985
159
G-1-20-iii
21.939.485
22.136.940
22.268.577
22.400.214
160
G-1-30-i
PROSEDUR TULANG BELAKANG RINGAN
8.459.235
8.535.369
8.586.124
8.636.879
161
G-1-30-ii
PROSEDUR TULANG BELAKANG SEDANG
22.079.415
22.278.130
22.410.607
22.543.083
162
G-1-30-iii
PROSEDUR TULANG BELAKANG BERAT
28.423.031
28.678.838
28.849.376
29.019.915
163
G-4-10-i
4.018.968
4.055.139
4.079.253
4.103.366
164
G-4-10-ii
4.918.168
4.962.432
4.991.941
5.021.450
165
G-4-10-iii
6.777.449
6.838.446
6.879.111
6.919.775
166
G-4-11-i
6.273.935
6.330.400
6.368.044
6.405.688
167
G-4-11-ii
7.277.765
7.343.264
7.386.931
7.430.598
168
G-4-11-iii
10.665.689
10.761.681
10.825.675
10.889.669
169
G-4-12-i
4.692.351
4.734.582
4.762.736
4.790.891
170
G-4-12-ii
5.912.362
5.965.574
6.001.048
6.036.522
171
G-4-12-iii
8.587.003
8.664.286
8.715.808
8.767.330
172
G-4-13-i
2.810.382
2.835.675
2.852.538
2.869.400
173
G-4-13-ii
4.918.168
4.962.432
4.991.941
5.021.450
174
G-4-13-iii
5.813.973
5.866.299
5.901.183
5.936.067
175
G-4-14-i
4.774.751
4.817.723
4.846.372
4.875.020
176
G-4-14-ii
7.856.076
7.926.781
7.973.917
8.021.054
177
G-4-14-iii
9.835.986
9.924.510
9.983.526
10.042.542
178
G-4-15-i
4.215.573
4.253.513
4.278.806
4.304.100
179
G-4-15-ii
5.344.397
5.392.497
5.424.563
5.456.630
180
G-4-15-iii
8.089.989
8.162.799
8.211.339
8.259.879
PROSEDUR PEMBULUH DARAH EXTRA

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT
PROSEDUR SARAF KRANIAL DAN PERIFER

RINGAN
SEDANG
BERAT
KECEDERAAN & GANGGUAN TULANG

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
TUMOR SISTEM PERSARAFAN & GANGGUAN
DEGENERATIF RINGAN
DEGENERATIF SEDANG
DEGENERATIF BERAT
SKLEROSIS MULTIPLE & ATAXIA CEREBELAR
RINGAN
SEDANG
BERAT
PERDARAHAN INTRA KRANIAL BUKAN
TRAUMATIK RINGAN
TRAUMATIK SEDANG
TRAUMATIK BERAT
KECEDERAAN PEMBULUH DARAH OTAK
DENGAN INFARK RINGAN
DENGAN INFARK SEDANG
DENGAN INFARK BERAT
KECEDERAAN PEMBULUH DARAH OTAK NON
SPESIFIK & PENYUMBATAN PRE-CEREBRAL
TANPA INFARK RINGAN
TANPA INFARK SEDANG
TANPA INFARK BERAT
-7No
Kode
INA-CBG
181
G-4-16-i
182
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
ISKEMIK TRANSIENT RINGAN
3.512.977
3.544.594
3.565.672
3.586.750
G-4-16-ii
ISKEMIK TRANSIENT SEDANG
5.253.690
5.300.973
5.332.495
5.364.017
183
G-4-16-iii
ISKEMIK TRANSIENT BERAT
9.534.508
9.620.318
9.677.525
9.734.732
184
G-4-17-i
4.528.493
4.569.249
4.596.420
4.623.591
185
G-4-17-ii
5.620.059
5.670.640
5.704.360
5.738.080
186
G-4-17-iii
9.419.265
9.504.039
9.560.554
9.617.070
187
G-4-18-i
4.215.573
4.253.513
4.278.806
4.304.100
188
G-4-18-ii
5.620.764
5.671.351
5.705.075
5.738.800
189
G-4-18-iii
6.323.359
6.380.270
6.418.210
6.456.150
190
G-4-19-i
3.512.977
3.544.594
3.565.672
3.586.750
191
G-4-19-ii
7.119.521
7.183.597
7.226.314
7.269.031
192
G-4-19-iii
10.620.065
10.715.646
10.779.366
10.843.087
193
G-4-20-i
MENINGITIS VIRUS RINGAN
2.459.084
2.481.216
2.495.970
2.510.725
194
G-4-20-ii
MENINGITIS VIRUS SEDANG
3.491.902
3.523.329
3.544.281
3.565.232
195
G-4-20-iii
MENINGITIS VIRUS BERAT
5.954.511
6.008.102
6.043.829
6.079.556
196
G-4-21-i
KOMA & STUPOR NON TRAUMA (RINGAN)
2.570.333
2.593.466
2.608.888
2.624.310
197
G-4-21-ii
KOMA & STUPOR NON TRAUMA (SEDANG)
5.326.380
5.374.317
5.406.276
5.438.234
198
G-4-21-iii
KOMA & STUPOR NON TRAUMA (BERAT)
6.271.614
6.328.058
6.365.688
6.403.317
199
G-4-22-i
SERANGAN KEJANG RINGAN
2.654.630
2.678.522
2.694.449
2.710.377
200
G-4-22-ii
SERANGAN KEJANG SEDANG
3.397.926
3.428.508
3.448.895
3.469.283
201
G-4-22-iii
SERANGAN KEJANG BERAT
3.981.945
4.017.782
4.041.674
4.065.566
202
G-4-23-i
MIGREN DAN SAKIT KEPALA LAIN (RINGAN)
2.810.382
2.835.675
2.852.538
2.869.400
203
G-4-23-ii
MIGREN DAN SAKIT KEPALA LAIN (SEDANG
3.512.977
3.544.594
3.565.672
3.586.750
204
G-4-23-iii
MIGREN DAN SAKIT KEPALA LAIN (BERAT)
5.021.552
5.066.746
5.096.876
5.127.005
205
G-4-24-i
TRAUMA KEPALA RINGAN
2.810.382
2.835.675
2.852.538
2.869.400
206
G-4-24-ii
TRAUMA KEPALA SEDANG
3.512.977
3.544.594
3.565.672
3.586.750
207
G-4-24-iii
TRAUMA KEPALA BERAT
7.382.142
7.448.581
7.492.874
7.537.167
208
G-4-25-i
GEGAR OTAK RINGAN
2.408.777
2.430.456
2.444.908
2.459.361
209
G-4-25-ii
GEGAR OTAK SEDANG
3.032.703
3.059.997
3.078.193
3.096.389
210
G-4-25-iii
GEGAR OTAK BERAT
4.018.973
4.055.144
4.079.258
4.103.372
211
G-4-26-i
4.215.573
4.253.513
4.278.806
4.304.100
212
G-4-26-ii
4.918.168
4.962.432
4.991.941
5.021.450
213
G-4-26-iii
9.388.095
9.472.588
9.528.917
9.585.245
GANGUAN PERSARAFAN KRANIAL DAN

PERIFER RINGAN
PERIFER SEDANG
PERIFER BERAT
INFEKSI TUBERKULOSA DAN BAKTERI SISTEM
PERSARAFAN RINGAN
PERSARAFAN SEDANG
PERSARAFAN BERAT
INFEKSI NON BAKTERI SISTEM PERSARAFAN
(TIDAK TERMASUK MENINGITIS VIRUS) RINGAN
(TIDAK TERMASUK MENINGITIS VIRUS)
SEDANG
(TIDAK TERMASUK MENINGITIS VIRUS) BERAT
GANGUAN-PENYAKIT SISTEM PERNAFASAN

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
-8No
Kode
INA-CBG
Deskripsi (INA-CBG)
214
H-1-20-i
215
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
PROSEDUR EKTRAOKULER DAN MATA RINGAN
3.643.836
3.676.630
3.698.493
3.720.356
H-1-20-ii
PROSEDUR EKTRAOKULER DAN MATA SEDANG
6.644.947
6.704.751
6.744.621
6.784.491
216
H-1-20-iii
PROSEDUR EKTRAOKULER DAN MATA BERAT
9.036.713
9.118.043
9.172.263
9.226.484
217
H-1-30-i
3.567.662
3.599.771
3.621.177
3.642.583
218
H-1-30-ii
4.067.135
4.103.739
4.128.142
4.152.545
219
H-1-30-iii
PROSEDUR LENSA DAN INTRA OKULER BERAT
6.785.868
6.846.940
6.887.656
6.928.371
220
H-4-10-i
INFEKSI MATA AKUT MAYOR (RINGAN)
4.215.573
4.253.513
4.278.806
4.304.100
221
H-4-10-ii
INFEKSI MATA AKUT MAYOR (SEDANG)
7.025.955
7.089.188
7.131.344
7.173.500
222
H-4-10-iii
INFEKSI MATA AKUT MAYOR (BERAT)
11.454.381
11.557.471
11.626.197
11.694.923
223
H-4-11-i
GANGGUAN PERSARAFAN MATA RINGAN
2.810.382
2.835.675
2.852.538
2.869.400
224
H-4-11-ii
GANGGUAN PERSARAFAN MATA SEDANG
3.207.180
3.236.044
3.255.287
3.274.530
225
H-4-11-iii
GANGGUAN PERSARAFAN MATA BERAT
4.585.967
4.627.241
4.654.756
4.682.272
226
H-4-12-i
GANGGUAN MATA LAIN-LAIN (RINGAN)
3.592.299
3.624.629
3.646.183
3.667.737
227
H-4-12-ii
GANGGUAN MATA LAIN-LAIN (SEDANG)
4.866.004
4.909.798
4.938.994
4.968.190
228
H-4-12-iii
GANGGUAN MATA LAIN-LAIN (BERAT)
8.118.595
8.191.663
8.240.374
8.289.086
229
I-1-01-i
60.630.623
61.176.298
61.540.082
61.903.866
230
I-1-01-ii
61.964.813
62.522.496
62.894.285
63.266.074
231
I-1-01-iii
97.810.268
98.690.560
99.277.422
99.864.284
232
I-1-02-i
33.637.520
33.940.258
34.142.083
34.343.908
233
I-1-02-ii
43.392.401
43.782.933
44.043.287
44.303.642
234
I-1-02-iii
53.483.657
53.965.010
54.285.912
54.606.814
235
I-1-03-i
20.391.387
20.574.910
20.697.258
20.819.607
236
I-1-03-ii
28.393.722
28.649.266
28.819.628
28.989.991
237
I-1-03-iii
41.644.126
42.018.923
42.268.788
42.518.653
238
I-1-04-i
22.795.886
23.001.049
23.137.824
23.274.600
239
I-1-04-ii
29.281.720
29.545.256
29.720.946
29.896.636
240
I-1-04-iii
62.422.548
62.984.351
63.358.886
63.733.421
241
I-1-05-i
44.520.247
44.920.930
45.188.051
45.455.173
242
I-1-05-ii
53.424.297
53.905.116
54.225.661
54.546.207
243
I-1-05-iii
73.511.495
74.173.099
74.614.168
75.055.237
244
I-1-06-i
18.929.757
19.100.125
19.213.704
19.327.282
PROSEDUR LENSA DAN INTRA OKULER

RINGAN
SEDANG
PROSEDUR TRANPLANTASI PARU ATAU/DAN

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
PROSEDUR KATUP JANTUNG DENGAN
KATETERISASI RINGAN
KATETERISASI SEDANG
KATETERISASI BERAT
PROSEDUR OPERASI KARDIOTORASIK
KOMPLEKS PADA JANTUNG ANOMALI RINGAN
KOMPLEKS PADA JANTUNG ANOMALI SEDANG
KOMPLEKS PADA JANTUNG ANOMALI BERAT
PROSEDUR KATUP JANTUNG TANPA
KATETERISASI JANTUNG RINGAN
KATETERISASI JANTUNG SEDANG
KATETERISASI JANTUNG BERAT
PROSEDUR PEMBEDAHAN BYPASS PEMBULUH
KORONER DENGAN KATETERISASI JANTUNG
RINGAN
SEDANG
BERAT
PROSEDUR KARDIOTORASIK LAIN RINGAN
-9No
Kode
INA-CBG
245
I-1-06-ii
246
I-1-06-iii
247
I-1-07-i
248
I-1-07-ii
249
I-1-07-iii
250
I-1-11-i
251
I-1-11-ii
252
I-1-11-iii
253
I-1-12-i
254
I-1-12-ii
255
I-1-12-iii
256
I-1-13-i
257
I-1-13-ii
258
I-1-13-iii
259
I-1-14-i
260
I-1-14-ii
261
I-1-14-iii
262
I-1-15-i
263
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
PROSEDUR KARDIOTORASIK LAIN SEDANG
28.518.761
28.775.429
28.946.542
29.117.655
PROSEDUR KARDIOTORASIK LAIN BERAT
64.318.104
64.896.967
65.282.876
65.668.784
24.894.064
25.118.111
25.267.475
25.416.839
30.711.885
30.988.292
31.172.563
31.356.835
33.506.467
33.808.025
34.009.064
34.210.103
4.735.458
4.778.077
4.806.490
4.834.903
5.265.356
5.312.744
5.344.336
5.375.928
7.006.584
7.069.643
7.111.682
7.153.722
16.089.776
16.234.584
16.331.123
16.427.661
22.325.315
22.526.243
22.660.195
22.794.147
31.138.545
31.418.792
31.605.623
31.792.454
5.986.010
6.039.884
6.075.800
6.111.716
6.941.100
7.003.570
7.045.217
7.086.863
18.106.464
18.269.423
18.378.061
18.486.700
34.626.859
34.938.501
35.146.262
35.354.023
43.036.239
43.423.565
43.681.783
43.940.000
56.392.313
56.899.844
57.238.198
57.576.552
PROSEDUR KATETERISASI JANTUNG RINGAN
9.978.497
10.068.303
10.128.174
10.188.045
I-1-15-ii
PROSEDUR KATETERISASI JANTUNG SEDANG
19.875.606
20.054.486
20.173.740
20.292.993
264
I-1-15-iii
PROSEDUR KATETERISASI JANTUNG BERAT
65.030.190
65.615.462
66.005.643
66.395.824
265
I-1-16-i
14.840.082
14.973.643
15.062.684
15.151.724
266
I-1-16-ii
38.584.214
38.931.472
39.162.978
39.394.483
267
I-1-16-iii
44.505.944
44.906.498
45.173.534
45.440.569
268
I-1-17-i
4.293.036
4.331.673
4.357.431
4.383.189
269
I-1-17-ii
8.892.433
8.972.465
9.025.820
9.079.174
270
I-1-17-iii
39.614.700
39.971.232
40.208.921
40.446.609
271
I-1-20-i
5.300.508
5.348.213
5.380.016
5.411.819
272
I-1-20-ii
8.803.488
8.882.719
8.935.540
8.988.361
273
I-1-20-iii
24.990.900
25.215.818
25.365.764
25.515.709
PROSEDUR PEMBULUH DARAH TORASIK

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
PROSEDUR DEFIBRILATOR JANTUNG DAN
PEMASANGAN SISTEM BANTUAN JANTUNG
RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
PROSEDUR PEMBULUH DARAH ABDOMINAL
KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT
PROSEDUR PEMASANGAN PACEMAKER
JANTUNG PERMANEN RINGAN
JANTUNG PERMANEN SEDANG
JANTUNG PERMANEN BERAT
PROSEDUR REVISI DEFIBRILATOR &

PACEMAKER JANTUNG TIDAK TERMASUK
PENGGANTIAN ALAT (RINGAN)
PENGGANTIAN ALAT (SEDANG)
PENGGANTIAN ALAT (BERAT)
PROSEDUR LIGASI DAN STRIPPING PEMBULUH
DARAH VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
PROSEDUR SISTIM PEREDARAN DARAH LAINLAIN RINGAN
PROSEDUR SISTIM PEREDARAN DARAH LAINLAIN SEDANG
PROSEDUR SISTIM PEREDARAN DARAH LAIN
BERAT
- 10 No
Kode
INA-CBG
274
I-1-30-i
275
I-1-30-ii
276
I-1-30-iii
277
I-1-40-i
278
I-1-40-ii
279
I-1-40-iii
280
I-4-10-i
281
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
16.836.151
16.987.676
17.088.693
17.189.710
35.022.595
35.337.798
35.547.934
35.758.069
54.272.302
54.760.752
55.086.386
55.412.020
15.694.770
15.836.023
15.930.192
16.024.360
38.800.148
39.149.350
39.382.150
39.614.951
51.823.811
52.290.225
52.601.168
52.912.111
INFARK MYOKARD AKUT RINGAN
5.939.480
5.992.935
6.028.572
6.064.209
I-4-10-ii
INFARK MYOKARD AKUT SEDANG
9.378.545
9.462.952
9.519.223
9.575.495
282
I-4-10-iii
INFARK MYOKARD AKUT BERAT
13.529.370
13.651.134
13.732.310
13.813.486
283
I-4-11-i
ENDOKARDITIS AKUT DAN SUBAKUT RINGAN
7.042.670
7.106.054
7.148.310
7.190.566
284
I-4-11-ii
ENDOKARDITIS AKUT DAN SUBAKUT SEDANG
8.715.331
8.793.769
8.846.061
8.898.353
285
I-4-11-iii
ENDOKARDITIS AKUT DAN SUBAKUT BERAT
16.121.549
16.266.642
16.363.372
16.460.101
286
I-4-12-i
KEGAGALAN JANTUNG RINGAN
6.168.647
6.224.165
6.261.177
6.298.188
287
I-4-12-ii
KEGAGALAN JANTUNG SEDANG
8.802.641
8.881.865
8.934.681
8.987.497
288
I-4-12-iii
10.874.156
10.972.023
11.037.268
11.102.513
5.541.141
5.591.011
5.624.258
5.657.505
8.050.146
8.122.598
8.170.899
8.219.200
18.267.482
18.431.890
18.541.495
18.651.100
PROSEDUR PENGGANTIAN ALAT

DEFIBRILATOR DAN PACEMAKER JANTUNG
RINGAN
SEDANG
BERAT
PROSEDUR KARDIOVASKULAR PERKUTAN
RINGAN
SEDANG
BERAT
KEGAGALAN JANTUNG BERAT

THROMBOPHLEBITIS PADA PEMBULUH DARAH
VENA RINGAN
THROMBOPHLEBITIS DALAM PEMBULUH
DARAH VENA SEDANG
DARAH VENA BERAT
289
I-4-13-i
290
I-4-13-ii
291
I-4-13-iii
292
I-4-14-i
CARDIAC ARREST, TIDAK DIKETAHUI RINGAN
3.446.078
3.477.092
3.497.769
3.518.445
293
I-4-14-ii
CARDIAC ARREST, TIDAK DIKETAHUI SEDANG
4.032.420
4.068.712
4.092.907
4.117.101
294
I-4-14-iii
CARDIAC ARREST, TIDAK DIKETAHUI BERAT
6.248.910
6.305.150
6.342.644
6.380.137
5.620.764
5.671.351
5.705.075
5.738.800
7.258.051
7.323.374
7.366.922
7.410.471
8.272.432
8.346.884
8.396.519
8.446.153
GANGUAN PEMBULUH DARAH PERIFER LAINLAIN (RINGAN)

GANGUAN PEMBULUH DARAH PERIFER LAINLAIN (SEDANG)
GANGUAN PEMBULUH DARAH PERIFER LAINLAIN (BERAT)
295
I-4-15-i
296
I-4-15-ii
297
I-4-15-iii
298
I-4-16-i
ATHEROSKLEROSIS RINGAN
4.215.573
4.253.513
4.278.806
4.304.100
299
I-4-16-ii
ATHEROSKLEROSIS SEDANG
6.831.992
6.893.480
6.934.472
6.975.464
300
I-4-16-iii
ATHEROSKLEROSIS BERAT
8.607.096
8.684.560
8.736.203
8.787.845
301
I-4-17-i
HIPERTENSI RINGAN
3.512.977
3.544.594
3.565.672
3.586.750
302
I-4-17-ii
HIPERTENSI SEDANG
5.342.732
5.390.816
5.422.873
5.454.929
303
I-4-17-iii
HIPERTENSI BERAT
6.499.689
6.558.186
6.597.184
6.636.182
I-4-18-i
GANGUAN KATUP JANTUNG KONGENITAL

RINGAN
5.011.941
5.057.049
5.087.120
5.117.192
304
- 11 No
Kode
INA-CBG
305
I-4-18-ii
306
I-4-18-iii
307
I-4-19-i
308
I-4-19-ii
309
I-4-19-iii
310
I-4-20-i
311
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
7.677.958
7.747.060
7.793.128
7.839.195
10.351.118
10.444.278
10.506.385
10.568.492
3.922.501
3.957.803
3.981.338
4.004.873
7.122.793
7.186.898
7.229.635
7.272.371
8.490.304
8.566.717
8.617.659
8.668.601
ANGINA PEKTORIS DAN NYERI DADA RINGAN
4.760.510
4.803.355
4.831.918
4.860.481
I-4-20-ii
ANGINA PEKTORIS DAN NYERI DADA SEDANG
5.484.464
5.533.824
5.566.731
5.599.637
312
I-4-20-iii
ANGINA PEKTORIS DAN NYERI DADA BERAT
7.278.796
7.344.305
7.387.978
7.431.651
313
I-4-21-i
SYNCOPE & COLLAPSE RINGAN
6.330.708
6.387.685
6.425.669
6.463.653
314
I-4-21-ii
SYNCOPE & COLLAPSE SEDANG
7.897.148
7.968.222
8.015.605
8.062.988
315
I-4-21-iii
SYNCOPE & COLLAPSE BERAT
10.773.384
10.870.345
10.934.985
10.999.625
316
I-4-22-i
KARDIOMIOPATHI RINGAN
4.475.656
4.515.937
4.542.791
4.569.645
317
I-4-22-ii
KARDIOMIOPATHI SEDANG
5.260.854
5.308.201
5.339.766
5.371.332
318
I-4-22-iii
KARDIOMIOPATHI BERAT
7.677.701
7.746.801
7.792.867
7.838.933
319
I-4-23-i
3.459.662
3.490.799
3.511.557
3.532.315
320
I-4-23-ii
4.247.668
4.285.897
4.311.383
4.336.869
321
I-4-23-iii
8.299.556
8.374.252
8.424.049
8.473.846
322
I-4-24-i
3.722.094
3.755.593
3.777.925
3.800.258
323
I-4-24-ii
9.293.039
9.376.676
9.432.434
9.488.192
324
I-4-24-iii
11.749.368
11.855.113
11.925.609
11.996.105
325
J-1-01-i
33.888.213
34.193.206
34.396.536
34.599.865
326
J-1-01-ii
36.911.839
37.244.046
37.465.517
37.686.988
327
J-1-01-iii
54.733.390
55.225.991
55.554.391
55.882.791
328
J-1-02-i
15.329.151
15.467.114
15.559.089
15.651.064
329
J-1-02-ii
16.421.606
16.569.400
16.667.930
16.766.459
330
J-1-02-iii
24.266.454
24.484.852
24.630.451
24.776.049
331
J-1-10-i
5.981.657
6.035.491
6.071.381
6.107.271
332
J-1-10-ii
14.447.874
14.577.905
14.664.592
14.751.280
333
J-1-10-iii
25.581.737
25.811.973
25.965.463
26.118.953
334
J-1-20-i
5.170.065
5.216.596
5.247.616
5.278.637
335
J-1-20-ii
7.519.452
7.587.127
7.632.243
7.677.360

SEDANG
GANGUAN-PENYAKIT KATUP JANTUNG
KONGENITAL BERAT
GANGGUAN KONDUKSI & ARITMIA JANTUNG
RINGAN
SEDANG
BERAT
KOMPLIKASI, REAKSI, MALFUNGSI DARI

PROSEDUR ATAU PEMASANGAN ALAT
KARDIOVASKULAR RINGAN
KARDIOVASKULAR SEDANG
KARDIOVASKULAR BERAT
DIAGNOSIS SISTEM PEMBULUH DARAH LAINLAIN (RINGAN)
DIAGNOSIS SISTEM PEMBULUH DARAH LAINLAIN (SEDANG)
DIAGNOSIS SISTEM PEMBULUH DARAH LAINLAIN (BERAT)
PROSEDUR VENTILASI MEKANIKAL LONG TERM
DENGAN TRAKEOSTOMI RINGAN
DENGAN TRAKEOSTOMI SEDANG
DENGAN TRAKEOSTOMI BERAT
TANPA TRAKEOSTOMI RINGAN
TANPA TRAKEOSTOMI SEDANG
TANPA TRAKEOSTOMI BERAT
PROSEDUR SISTEM PERNAFASAN KOMPLEKS
RINGAN
SEDANG
BERAT
PROSEDUR SISTEM PERNAFASAN NON
KOMPLEKS RINGAN
KOMPLEKS SEDANG
- 12 No
Kode
INA-CBG
336
J-1-20-iii
337
J-1-30-i
338
J-1-30-ii
339
J-1-30-iii
340
J-4-10-i
341
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
11.306.933
11.408.695
11.476.537
11.544.378
3.486.460
3.517.839
3.538.757
3.559.676
18.929.148
19.099.511
19.213.086
19.326.660
57.089.480
57.603.285
57.945.822
58.288.359
KISTA FIBROSIS RINGAN
4.460.900
4.501.048
4.527.813
4.554.579
J-4-10-ii
KISTA FIBROSIS SEDANG
6.378.551
6.435.958
6.474.229
6.512.500
342
J-4-10-iii
KISTA FIBROSIS BERAT
9.649.795
9.736.643
9.794.542
9.852.441
343
J-4-11-i
KEGAGALAN PERNAFASAN RINGAN
2.538.532
2.561.378
2.576.610
2.591.841
344
J-4-11-ii
KEGAGALAN PERNAFASAN SEDANG
3.533.578
3.565.380
3.586.582
3.607.783
345
J-4-11-iii
KEGAGALAN PERNAFASAN BERAT
5.063.708
5.109.281
5.139.663
5.170.045
346
J-4-12-i
EMBOLI PARU RINGAN
4.303.735
4.342.468
4.368.291
4.394.113
347
J-4-12-ii
EMBOLI PARU SEDANG
5.573.189
5.623.348
5.656.787
5.690.226
348
J-4-12-iii
EMBOLI PARU BERAT
7.442.431
7.509.413
7.554.068
7.598.722
349
J-4-13-i
TRAUMA DADA MAYOR TRAUMA RINGAN
5.979.868
6.033.687
6.069.566
6.105.446
350
J-4-13-ii
TRAUMA DADA MAYOR TRAUMA SEDANG
8.790.407
8.869.520
8.922.263
8.975.005
351
J-4-13-iii
TRAUMA DADA MAYOR TRAUMA BERAT
14.291.885
14.420.512
14.506.264
14.592.015
352
J-4-14-i
TUMOR PARU RINGAN
4.215.573
4.253.513
4.278.806
4.304.100
353
J-4-14-ii
TUMOR PARU SEDANG
6.826.336
6.887.773
6.928.731
6.969.689
354
J-4-14-iii
TUMOR PARU BERAT
8.116.166
8.189.212
8.237.909
8.286.606
4.215.573
4.253.513
4.278.806
4.304.100
5.023.375
5.068.585
5.098.726
5.128.866
6.821.376
6.882.768
6.923.696
6.964.624
3.512.977
3.544.594
3.565.672
3.586.750
4.918.168
4.962.432
4.991.941
5.021.450
8.871.858
8.951.705
9.004.936
9.058.167

KOMPLEKS BERAT
PROSEDUR SISTEM PERNAFASAN MODERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
PERADANGAN DAN INFEKSI PERNAFASAN

RINGAN
SEDANG
BERAT
SIMPLE PNEUMONIA & WHOOPING COUGH
RINGAN
SEDANG
BERAT
355
J-4-15-i
356
J-4-15-ii
357
J-4-15-iii
358
J-4-16-i
359
J-4-16-ii
360
J-4-16-iii
361
J-4-17-i
PENYAKIT PARU OBSTRUKTIF KRONIS RINGAN
3.512.977
3.544.594
3.565.672
3.586.750
362
J-4-17-ii
PENYAKIT PARU OBSTRUKTIF KRONIS SEDANG
4.215.573
4.253.513
4.278.806
4.304.100
363
J-4-17-iii
PENYAKIT PARU OBSTRUKTIF KRONIS BERAT
7.750.088
7.819.839
7.866.340
7.912.840
364
J-4-18-i
ASTHMA & BRONKIOLITIS RINGAN
2.810.382
2.835.675
2.852.538
2.869.400
365
J-4-18-ii
ASTHMA & BRONKIOLITIS SEDANG
3.864.275
3.899.054
3.922.239
3.945.425
366
J-4-18-iii
ASTHMA & BRONKIOLITIS BERAT
4.068.845
4.105.465
4.129.878
4.154.291
367
J-4-19-i
PENYAKIT PARU INTERSTITIAL RINGAN
4.918.168
4.962.432
4.991.941
5.021.450
368
J-4-19-ii
PENYAKIT PARU INTERSTITIAL SEDANG
5.620.764
5.671.351
5.705.075
5.738.800
- 13 No
Kode
INA-CBG
369
J-4-19-iii
370
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
PENYAKIT PARU INTERSTITIAL BERAT
8.805.585
8.884.836
8.937.669
8.990.503
J-4-20-i
PLEURAL EFUSI DAN PNEUMOTORAK RINGAN
4.918.168
4.962.432
4.991.941
5.021.450
371
J-4-20-ii
PLEURAL EFUSI DAN PNEUMOTORAK SEDANG
5.620.764
5.671.351
5.705.075
5.738.800
372
J-4-20-iii
13.556.157
13.678.162
13.759.499
13.840.836
2.810.382
2.835.675
2.852.538
2.869.400
6.933.725
6.996.129
7.037.731
7.079.333
9.889.760
9.978.768
10.038.106
10.097.445
7.571.659
7.639.804
7.685.234
7.730.664
9.531.465
9.617.249
9.674.437
9.731.626
11.162.987
11.263.454
11.330.432
11.397.410
PLEURAL EFUSI DAN PNEUMOTORAK BERAT

GEJALA, TANDA DAN DIAGNOSIS SISTEM
PERNAFASAN LAIN-LAIN (RINGAN)
PERNAFASAN LAIN-LAIN (SEDANG)
PERNAFASAN LAIN-LAIN (BERAT)
PROSEDUR NON KOMPLEKS USUS HALUS &
USUS BESAR (RINGAN)
USUS BESAR (SEDANG)
USUS BESAR (BERAT)
373
J-4-21-i
374
J-4-21-ii
375
J-4-21-iii
376
K-1-10-i
377
K-1-10-ii
378
K-1-10-iii
379
K-1-11-i
PROSEDUR ADHESIOLISIS PERITONEAL RINGAN
5.872.597
5.925.450
5.960.686
5.995.921
380
K-1-11-ii
PROSEDUR ADHESIOLISIS PERITONEAL SEDANG
7.710.011
7.779.401
7.825.661
7.871.921
381
K-1-11-iii
PROSEDUR ADHESIOLISIS PERITONEAL BERAT
19.566.489
19.742.588
19.859.987
19.977.386
382
K-1-12-i
3.159.007
3.187.439
3.206.393
3.225.347
383
K-1-12-ii
4.117.164
4.154.218
4.178.921
4.203.624
384
K-1-12-iii
8.189.905
8.263.614
8.312.753
8.361.893
385
K-1-13-i
PROSEDUR APPENDIK RINGAN
3.588.200
3.620.493
3.642.023
3.663.552
386
K-1-13-ii
PROSEDUR APPENDIK SEDANG
6.267.554
6.323.962
6.361.567
6.399.173
387
K-1-13-iii
PROSEDUR APPENDIK BERAT
6.702.923
6.763.249
6.803.467
6.843.684
388
K-1-14-i
5.798.743
5.850.931
5.885.724
5.920.516
389
K-1-14-ii
6.811.280
6.872.582
6.913.449
6.954.317
390
K-1-14-iii
16.771.347
16.922.289
17.022.917
17.123.545
391
K-1-20-i
PROSEDUR INTESTINAL KOMPLEKS (RINGAN)
11.251.262
11.352.523
11.420.031
11.487.539
392
K-1-20-ii
PROSEDUR INTESTINAL KOMPLEKS (SEDANG)
15.703.795
15.845.129
15.939.352
16.033.574
393
K-1-20-iii
PROSEDUR INTESTINAL KOMPLEKS (BERAT)
33.544.047
33.845.943
34.047.208
34.248.472
394
K-1-30-i
7.406.141
7.472.796
7.517.233
7.561.670
395
K-1-30-ii
14.434.097
14.564.003
14.650.608
14.737.213
396
K-1-30-iii
21.273.144
21.464.602
21.592.241
21.719.880
397
K-1-40-i
7.440.362
7.507.326
7.551.968
7.596.610
398
K-1-40-ii
8.187.380
8.261.066
8.310.190
8.359.315
399
K-1-40-iii
13.577.981
13.700.183
13.781.651
13.863.119
400
K-1-50-i
PROSEDUR ANAL RINGAN
5.675.201
5.726.278
5.760.329
5.794.381
401
K-1-50-ii
PROSEDUR ANAL SEDANG
7.349.653
7.415.800
7.459.898
7.503.996
PROSEDUR HERNIA TIDAK TERMASUK

INGUINAL & FEMORAL (RINGAN)
INGUINAL & FEMORAL (SEDANG)
INGUINAL & FEMORAL (BERAT)
PROSEDUR HERNIA INGUINAL DAN FEMORAL

RINGAN
SEDANG
BERAT
PROSEDUR DUODENUM, ESOFAGUS &

LAMBUNG NON KOMPLEKS (RINGAN)
LAMBUNG NON KOMPLEKS (SEDANG)
LAMBUNG NON KOMPLEKS (BERAT)
PROSEDUR SISTEM PENCERNAAN LAIN-LAIN
(RINGAN)
(SEDANG)
(BERAT)
- 14 No
Kode
INA-CBG
402
K-1-50-iii
PROSEDUR ANAL BERAT
403
K-4-10-i
404
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
10.434.553
10.528.464
10.591.071
10.653.679
TUMOR PENCERNAAN RINGAN
4.298.557
4.337.244
4.363.035
4.388.826
K-4-10-ii
TUMOR PENCERNAAN SEDANG
5.620.764
5.671.351
5.705.075
5.738.800
405
K-4-10-iii
TUMOR PENCERNAAN BERAT
23.612.514
23.825.026
23.966.702
24.108.377
406
K-4-11-i
GASTRITIS & ULKUS PEPTIKUM RINGAN
2.810.382
2.835.675
2.852.538
2.869.400
407
K-4-11-ii
GASTRITIS & ULKUS PEPTIKUM SEDANG
4.215.573
4.253.513
4.278.806
4.304.100
408
K-4-11-iii
GASTRITIS & ULKUS PEPTIKUM BERAT
7.661.215
7.730.166
7.776.133
7.822.100
409
K-4-12-i
GANGGUAN ESOFAGUS RINGAN
2.810.382
2.835.675
2.852.538
2.869.400
410
K-4-12-ii
GANGGUAN ESOFAGUS SEDANG
3.787.300
3.821.386
3.844.110
3.866.834
411
K-4-12-iii
GANGGUAN ESOFAGUS BERAT
9.089.251
9.171.054
9.225.590
9.280.125
412
K-4-13-i
4.215.573
4.253.513
4.278.806
4.304.100
413
K-4-13-ii
5.460.205
5.509.347
5.542.108
5.574.869
414
K-4-13-iii
8.930.506
9.010.880
9.064.463
9.118.046
415
K-4-14-i
3.512.977
3.544.594
3.565.672
3.586.750
416
K-4-14-ii
4.754.448
4.797.238
4.825.765
4.854.292
417
K-4-14-iii
7.191.557
7.256.281
7.299.430
7.342.579
418
K-4-15-i
3.512.977
3.544.594
3.565.672
3.586.750
419
K-4-15-ii
6.605.356
6.664.804
6.704.436
6.744.068
420
K-4-15-iii
9.398.232
9.482.816
9.539.206
9.595.595
421
K-4-16-i
INFEKSI-INFEKSI GASTROINTESTINAL RINGAN
3.512.977
3.544.594
3.565.672
3.586.750
422
K-4-16-ii
INFEKSI-INFEKSI GASTROINTESTINAL SEDANG
4.215.573
4.253.513
4.278.806
4.304.100
423
K-4-16-iii
INFEKSI-INFEKSI GASTROINTESTINAL BERAT
4.918.168
4.962.432
4.991.941
5.021.450
424
K-4-17-i
2.549.529
2.572.474
2.587.772
2.603.069
425
K-4-17-ii
3.698.661
3.731.949
3.754.141
3.776.333
426
K-4-17-iii
4.922.540
4.966.843
4.996.378
5.025.913
427
K-4-18-i
2.810.382
2.835.675
2.852.538
2.869.400
428
K-4-18-ii
4.215.573
4.253.513
4.278.806
4.304.100
429
K-4-18-iii
5.161.263
5.207.715
5.238.682
5.269.650
430
L-1-20-i
25.908.300
26.141.475
26.296.925
26.452.374
431
L-1-20-ii
27.066.602
27.310.201
27.472.601
27.635.000
432
L-1-20-iii
41.346.356
41.718.473
41.966.552
42.214.630
DIVERTIKULITIS, DIVERTIKULOSIS DAN

PENYAKIT PERADANGAN USUS BESAR
(RINGAN)
(SEDANG)
PENYAKIT PERADANGAN USUS BESAR (BERAT)
INSUFISIENSI PEMBULUH DARAH
GASTROINTESTINAL RINGAN
GASTROINTESTINAL SEDANG
GASTROINTESTINAL BERAT
OBSTRUKSI SALURAN GASTROINTESTINAL
RINGAN
SEDANG
BERAT
NYERI ABDOMEN & GASTROENTERITIS LAINLAIN (RINGAN)

NYERI ABDOMEN & GASTROENTERITIS LAINLAIN (SEDANG)
NYERI ABDOMEN & GASTROENTERITIS LAINLAIN (BERAT)
DIAGNOSIS SISTEM PENCERNAAN LAIN-LAIN
(RINGAN)
(SEDANG)
(BERAT)
PROSEDUR PEMINDAHAN KULIT PADA LUKA
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
- 15 No
Kode
INA-CBG
433
L-1-30-i
434
L-1-30-ii
435
L-1-30-iii
436
L-1-40-i
437
L-1-40-ii
438
L-1-40-iii
439
L-1-50-i
440
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
11.766.361
11.872.258
11.942.856
12.013.455
17.043.612
17.197.004
17.299.266
17.401.528
17.975.693
18.137.474
18.245.328
18.353.182
4.750.914
4.793.672
4.822.178
4.850.683
10.692.882
10.789.118
10.853.275
10.917.433
18.121.609
18.284.704
18.393.434
18.502.163
PROSEDUR PADA PAYUDARA RINGAN
9.464.574
9.549.755
9.606.543
9.663.330
L-1-50-ii
PROSEDUR PADA PAYUDARA SEDANG
16.388.517
16.536.014
16.634.345
16.732.676
441
L-1-50-iii
PROSEDUR PADA PAYUDARA BERAT
20.410.833
20.594.530
20.716.995
20.839.460
442
L-4-10-i
PENYAKIT KULIT MAYOR RINGAN
4.215.573
4.253.513
4.278.806
4.304.100
443
L-4-10-ii
PENYAKIT KULIT MAYOR SEDANG
4.918.168
4.962.432
4.991.941
5.021.450
444
L-4-10-iii
PENYAKIT KULIT MAYOR BERAT
8.974.273
9.055.041
9.108.887
9.162.732
445
L-4-11-i
TUMOR PAYUDARA RINGAN
3.596.520
3.628.888
3.650.468
3.672.047
446
L-4-11-ii
TUMOR PAYUDARA SEDANG
4.927.169
4.971.514
5.001.077
5.030.640
447
L-4-11-iii
TUMOR PAYUDARA BERAT
13.361.867
13.482.123
13.562.295
13.642.466
448
L-4-12-i
PERADANGAN KULIT/CELLULITIS RINGAN
4.215.573
4.253.513
4.278.806
4.304.100
449
L-4-12-ii
PERADANGAN KULIT/CELLULITIS SEDANG
5.579.223
5.629.436
5.662.911
5.696.387
450
L-4-12-iii
PERADANGAN KULIT/CELLULITIS BERAT
10.371.888
10.465.235
10.527.466
10.589.697
451
L-4-13-i
2.386.746
2.408.227
2.422.547
2.436.867
452
L-4-13-ii
2.810.382
2.835.675
2.852.538
2.869.400
453
L-4-13-iii
4.128.303
4.165.457
4.190.227
4.214.997
454
L-4-14-i
2.810.382
2.835.675
2.852.538
2.869.400
455
L-4-14-ii
4.215.573
4.253.513
4.278.806
4.304.100
456
L-4-14-iii
5.945.355
5.998.863
6.034.536
6.070.208
457
M-1-01-i
13.701.707
13.825.022
13.907.232
13.989.443
458
M-1-01-ii
15.293.321
15.430.961
15.522.721
15.614.481
459
M-1-01-iii
21.482.973
21.676.320
21.805.218
21.934.115
460
M-1-02-i
PROSEDUR AMPUTASI RINGAN
8.753.519
8.832.301
8.884.822
8.937.343
461
M-1-02-ii
PROSEDUR AMPUTASI SEDANG
14.371.614
14.500.958
14.587.188
14.673.418
462
M-1-02-iii
PROSEDUR AMPUTASI BERAT
26.026.334
26.260.571
26.416.729
26.572.887
23.519.481
23.731.157
23.872.274
24.013.390
28.250.255
28.504.507
28.674.008
28.843.510
29.340.180
29.604.241
29.780.283
29.956.324
463
M-1-03-i
464
M-1-03-ii
465
M-1-03-iii
PROSEDUR PEMINDAHAN KULIT TANPA LUKA

BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
PROSEDUR PADA KULIT, JARINGAN BAWAH
KULIT DAN PAYUDARA RINGAN
KULIT DAN PAYUDARA SEDANG
KULIT DAN PAYUDARA BERAT
TRAUMA PADA KULIT, JARINGAN BAWAH

GANGGUAN PADA KULIT & PAYUDARA LAINLAIN (RINGAN)
GANGGUAN PADA KULIT & PAYUDARA LAINLAIN (SEDANG)
GANGGUAN PADA KULIT & PAYUDARA LAINLAIN (BERAT)
PROSEDUR BILATERAL DAN MULTIPLE SENDI
ANGGOTA TUBUH BAWAH MAYOR (RINGAN)
ANGGOTA TUBUH BAWAH MAYOR (SEDANG)
ANGGOTA TUBUH BAWAH MAYOR (BERAT)
PROSEDUR FUSI TULANG BELAKANG PADA

LENGKUNGAN TULANG BELAKANG RINGAN
LENGKUNGAN TULANG BELAKANG SEDANG
LENGKUNGAN TULANG BELAKANG BERAT
- 16 No
Kode
INA-CBG
466
M-1-04-i
467
M-1-04-ii
468
M-1-04-iii
469
M-1-05-i
470
M-1-05-ii
471
M-1-05-iii
472
M-1-07-i
473
M-1-07-ii
474
M-1-07-iii
475
M-1-10-i
476
M-1-10-ii
477
M-1-10-iii
478
M-1-20-i
479
M-1-20-ii
480
M-1-20-iii
481
M-1-30-i
482
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.774.434
5.826.404
5.861.051
5.895.697
7.402.765
7.469.389
7.513.806
7.558.223
9.263.164
9.346.533
9.402.112
9.457.691
8.995.459
9.076.419
9.130.391
9.184.364
10.396.341
10.489.908
10.552.286
10.614.664
17.707.799
17.867.170
17.973.416
18.079.663
11.008.269
11.107.343
11.173.393
11.239.442
14.747.640
14.880.369
14.968.855
15.057.341
30.042.341
30.312.722
30.492.976
30.673.230
6.205.889
6.261.742
6.298.977
6.336.213
23.060.925
23.268.473
23.406.839
23.545.204
49.215.786
49.658.728
49.954.022
50.249.317
6.139.228
6.194.481
6.231.316
6.268.152
8.755.808
8.834.610
8.887.145
8.939.680
17.033.744
17.187.048
17.289.250
17.391.453
PROSEDUR KAKI RINGAN
3.672.176
3.705.226
3.727.259
3.749.292
M-1-30-ii
PROSEDUR KAKI SEDANG
7.587.650
7.655.938
7.701.464
7.746.990
483
M-1-30-iii
PROSEDUR KAKI BERAT
11.319.173
11.421.046
11.488.961
11.556.876
484
M-1-40-i
4.113.468
4.150.489
4.175.170
4.199.851
485
M-1-40-ii
7.571.659
7.639.804
7.685.234
7.730.664
486
M-1-40-iii
13.250.404
13.369.657
13.449.160
13.528.662
487
M-1-50-i
PROSEDUR JARINGAN LUNAK RINGAN
4.914.021
4.958.248
4.987.732
5.017.216
488
M-1-50-ii
PROSEDUR JARINGAN LUNAK SEDANG
9.892.041
9.981.069
10.040.421
10.099.774
489
M-1-50-iii
PROSEDUR JARINGAN LUNAK BERAT
15.143.319
15.279.608
15.370.468
15.461.328
490
M-1-60-i
3.708.536
3.741.912
3.764.164
3.786.415
491
M-1-60-ii
7.424.512
7.491.333
7.535.880
7.580.427
492
M-1-60-iii
12.921.278
13.037.569
13.115.097
13.192.625
493
M-1-70-i
4.967.947
5.012.658
5.042.466
5.072.273
494
M-1-70-ii
10.137.071
10.228.305
10.289.127
10.349.950
495
M-1-70-iii
16.342.184
16.489.263
16.587.316
16.685.369
PROSEDUR PADA SENDI TUNGKAI/ANGGOTA

TUBUH BAGIAN BAWAH MAYOR (RINGAN)
TUBUH BAGIAN BAWAH MAYOR (SEDANG)
TUBUH BAGIAN BAWAH MAYOR (BERAT)
PROSEDUR PADA SENDI LENGAN/ANGGOTA
PROSEDUR FUSI TULANG BELAKANG SELAIN
PROSEDUR KRANIAL DAN REKONSTRUKSI
TULANG WAJAH RINGAN
TULANG WAJAH SEDANG
TULANG WAJAH BERAT
PROSEDUR PAHA DAN SENDI PANGGUL SELAIN
SENDI MAYOR RINGAN
SENDI MAYOR SEDANG
SENDI MAYOR BERAT
PROSEDUR EKSISI LOKAL DAN

PENGANGKATAN ALAT FIKSASI INTERNAL
RINGAN
SEDANG
BERAT
PROSEDUR SISTEM MUSKULOSKLETAL &

JARINGAN PENGHUBUNG LAIN-LAIN (RINGAN)
JARINGAN PENGHUBUNG LAIN-LAIN (SEDANG)
JARINGAN PENGHUBUNG LAIN-LAIN (BERAT)
PROSEDUR LUTUT DAN TUNGKAI BAWAH
SELAIN KAKI (RINGAN)
SELAIN KAKI (SEDANG)
SELAIN KAKI (BERAT)
- 17 No
Kode
INA-CBG
496
M-1-80-i
497
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
PROSEDUR ANGGOTA TUBUH ATAS RINGAN
4.002.820
4.038.846
4.062.863
4.086.880
M-1-80-ii
PROSEDUR ANGGOTA TUBUH ATAS SEDANG
6.051.446
6.105.909
6.142.218
6.178.526
498
M-1-80-iii
PROSEDUR ANGGOTA TUBUH ATAS BERAT
13.931.996
14.057.384
14.140.976
14.224.568
499
M-4-10-i
FRAKTUR FEMUR RINGAN
2.810.382
2.835.675
2.852.538
2.869.400
500
M-4-10-ii
FRAKTUR FEMUR SEDANG
4.215.573
4.253.513
4.278.806
4.304.100
501
M-4-10-iii
FRAKTUR FEMUR BERAT
8.213.120
8.287.038
8.336.317
8.385.596
3.512.977
3.544.594
3.565.672
3.586.750
7.696.841
7.766.113
7.812.294
7.858.475
13.661.713
13.784.669
13.866.639
13.948.609
2.810.382
2.835.675
2.852.538
2.869.400
5.113.487
5.159.508
5.190.189
5.220.870
9.237.611
9.320.749
9.376.175
9.431.601
4.679.895
4.722.014
4.750.094
4.778.173
7.025.955
7.089.188
7.131.344
7.173.500
13.921.516
14.046.810
14.130.339
14.213.868
FRAKTUR PELVIS ATAU DISLOKASI SENDI

PANGGUL RINGAN
PANGGUL SEDANG
PANGGUL BERAT
FRAKTUR/DISLOKASI SELAIN FEMUR DAN
PELVIS RINGAN
PELVIS SEDANG
PELVIS BERAT
TUMOR MUSKULOSKLETAL,JARINGAN
KONEKTIF DAN FRAKTUR PATOLOGIS RINGAN
KONEKTIF DAN FRAKTUR PATOLOGIS SEDANG
KONEKTIF DAN FRAKTUR PATOLOGIS BERAT
502
M-4-11-i
503
M-4-11-ii
504
M-4-11-iii
505
M-4-12-i
506
M-4-12-ii
507
M-4-12-iii
508
M-4-13-i
509
M-4-13-ii
510
M-4-13-iii
511
M-4-14-i
OSTEOMIELITIS RINGAN
5.328.301
5.376.255
5.408.225
5.440.195
512
M-4-14-ii
OSTEOMIELITIS SEDANG
6.582.306
6.641.547
6.681.040
6.720.534
513
M-4-14-iii
OSTEOMIELITIS BERAT
9.859.585
9.948.321
10.007.479
10.066.636
514
M-4-15-i
ARTRITIS SEPSIS RINGAN
3.163.179
3.191.648
3.210.627
3.229.606
515
M-4-15-ii
ARTRITIS SEPSIS SEDANG
4.217.839
4.255.799
4.281.106
4.306.413
516
M-4-15-iii
ARTRITIS SEPSIS BERAT
11.944.123
12.051.620
12.123.285
12.194.950
517
M-4-16-i
GANGGUAN JARINGAN KONEKTIF RINGAN
3.512.977
3.544.594
3.565.672
3.586.750
518
M-4-16-ii
GANGGUAN JARINGAN KONEKTIF SEDANG
5.620.764
5.671.351
5.705.075
5.738.800
519
M-4-16-iii
GANGGUAN JARINGAN KONEKTIF BERAT
9.427.426
9.512.273
9.568.838
9.625.402
520
M-4-17-i
3.512.977
3.544.594
3.565.672
3.586.750
521
M-4-17-ii
4.918.168
4.962.432
4.991.941
5.021.450
522
M-4-17-iii
6.868.483
6.930.299
6.971.510
7.012.721
523
M-4-18-i
3.714.316
3.747.745
3.770.031
3.792.317
524
M-4-18-ii
5.620.764
5.671.351
5.705.075
5.738.800
525
M-4-18-iii
6.299.263
6.355.956
6.393.752
6.431.548
526
M-4-19-i
2.761.644
2.786.499
2.803.069
2.819.639
527
M-4-19-ii
4.651.493
4.693.357
4.721.266
4.749.175
MASALAH BAGIAN PUNGGUNG/PINGGANG

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
PENYAKIT TULANG DAN SENDI LAIN-LAIN
RINGAN
SEDANG
BERAT
MALFUNGSI, REAKSI ATAU KOMPLIKASI DARI
ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
- 18 No
Kode
INA-CBG
528
M-4-19-iii
529
M-4-20-i
530
M-4-20-ii
531
M-4-20-iii
532
M-4-21-i
533
M-4-21-ii
534
M-4-21-iii
535
N-1-01-i
536
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
9.084.710
9.166.473
9.220.981
9.275.489
2.810.382
2.835.675
2.852.538
2.869.400
4.215.573
4.253.513
4.278.806
4.304.100
4.671.848
4.713.895
4.741.926
4.769.957
2.810.382
2.835.675
2.852.538
2.869.400
3.512.977
3.544.594
3.565.672
3.586.750
8.065.594
8.138.185
8.186.578
8.234.972
PROSEDUR PENCANGKOKAN GINJAL RINGAN
7.604.133
7.672.570
7.718.195
7.763.820
N-1-01-ii
PROSEDUR PENCANGKOKAN GINJAL SEDANG
10.284.418
10.376.978
10.438.685
10.500.391
537
N-1-01-iii
PROSEDUR PENCANGKOKAN GINJAL BERAT
21.806.027
22.002.281
22.133.117
22.263.953
538
N-1-11-i
9.462.678
9.547.842
9.604.618
9.661.394
539
N-1-11-ii
12.798.058
12.913.241
12.990.029
13.066.817
540
N-1-11-iii
27.135.691
27.379.912
27.542.726
27.705.540
5.412.852
5.461.568
5.494.045
5.526.522
11.916.823
12.024.075
12.095.576
12.167.077
21.719.153
21.914.625
22.044.940
22.175.255

ORTOPEDIK BERAT
TANDA-TANDA, GEJALA, MUSKULOSKLETAL ,
KESELEO DAN PERADANGAN MINOR (RINGAN)
KESELEO DAN PERADANGAN MINOR (SEDANG)
KESELEO DAN PERADANGAN MINOR (BERAT)
DIAGNOSIS SISTEM MUSKULOSKLETAL &
PROSEDUR KANDUNG KEMIH KOMPLEK

RINGAN
SEDANG
PROSEDUR KANDUNG KEMIH KOMPLEK BERAT
PROSEDUR MEMBUAT BARU, MEREVISI DAN
MEMINDAHKAN ALAT DIALISIS RINGAN
MEMINDAHKAN ALAT DIALISIS SEDANG
MEMINDAHKAN ALAT DIALISIS BERAT
541
N-1-12-i
542
N-1-12-ii
543
N-1-12-iii
544
N-1-20-i
PROSEDUR SALURAN URIN ATAS RINGAN
6.935.280
6.997.697
7.039.309
7.080.921
545
N-1-20-ii
PROSEDUR SALURAN URIN ATAS SEDANG
13.750.194
13.873.946
13.956.447
14.038.948
546
N-1-20-iii
PROSEDUR SALURAN URIN ATAS BERAT
15.728.976
15.870.537
15.964.910
16.059.284
547
N-1-30-i
8.250.739
8.324.996
8.374.500
8.424.005
548
N-1-30-ii
12.538.028
12.650.870
12.726.098
12.801.326
549
N-1-30-iii
14.433.337
14.563.237
14.649.837
14.736.437
550
N-1-40-i
7.434.724
7.501.636
7.546.245
7.590.853
551
N-1-40-ii
10.078.033
10.168.736
10.229.204
10.289.672
552
N-1-40-iii
11.721.044
11.826.533
11.896.860
11.967.186
553
N-4-10-i
3.512.977
3.544.594
3.565.672
3.586.750
554
N-4-10-ii
4.243.101
4.281.288
4.306.747
4.332.206
555
N-4-10-iii
10.296.154
10.388.820
10.450.597
10.512.374
556
N-4-11-i
PERADANGAN GINJAL RINGAN
2.426.671
2.448.511
2.463.071
2.477.631
557
N-4-11-ii
PERADANGAN GINJAL SEDANG
4.215.573
4.253.513
4.278.806
4.304.100
558
N-4-11-iii
PERADANGAN GINJAL BERAT
5.269.466
5.316.891
5.348.508
5.380.125
559
N-4-12-i
INFEKSI GINJAL DAN SALURAN URIN RINGAN
2.810.382
2.835.675
2.852.538
2.869.400
PROSEDUR KANDUNG KEMIH DAN SALURAN

URIN BAWAH RINGAN
URIN BAWAH SEDANG
URIN BAWAH BERAT
PROSEDUR PADA URETRA DAN TRANSURETRA
RINGAN
SEDANG
BERAT
TUMOR GINJAL & SALURAN URIN & GAGAL
GINJAL RINGAN
GINJAL SEDANG
GINJAL BERAT
- 19 No
Kode
INA-CBG
560
N-4-12-ii
561
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
INFEKSI GINJAL DAN SALURAN URIN SEDANG
4.215.573
4.253.513
4.278.806
4.304.100
N-4-12-iii
INFEKSI GINJAL DAN SALURAN URIN BERAT
6.999.237
7.062.230
7.104.225
7.146.221
562
N-4-13-i
BATU URIN RINGAN
3.512.977
3.544.594
3.565.672
3.586.750
563
N-4-13-ii
BATU URIN SEDANG
4.215.573
4.253.513
4.278.806
4.304.100
564
N-4-13-iii
BATU URIN BERAT
9.930.190
10.019.562
10.079.143
10.138.724
565
N-4-14-i
2.434.312
2.456.220
2.470.826
2.485.432
566
N-4-14-ii
3.748.534
3.782.270
3.804.762
3.827.253
567
N-4-14-iii
6.078.927
6.133.637
6.170.111
6.206.584
568
N-4-15-i
3.257.653
3.286.972
3.306.518
3.326.064
569
N-4-15-ii
4.470.514
4.510.749
4.537.572
4.564.395
570
N-4-15-iii
5.101.663
5.147.578
5.178.188
5.208.798
571
N-4-16-i
3.512.977
3.544.594
3.565.672
3.586.750
572
N-4-16-ii
5.620.764
5.671.351
5.705.075
5.738.800
573
N-4-16-iii
11.819.630
11.926.007
11.996.925
12.067.842
574
O-6-10-i
4.769.415
4.812.340
4.840.956
4.869.573
575
O-6-10-ii
5.217.671
5.264.630
5.295.936
5.327.242
576
O-6-10-iii
5.567.301
5.617.407
5.650.810
5.684.214
577
O-6-11-i
3.269.076
3.298.498
3.318.112
3.337.727
578
O-6-11-ii
4.185.778
4.223.450
4.248.565
4.273.679
579
O-6-11-iii
7.093.595
7.157.437
7.199.998
7.242.560
580
O-6-12-i
2.841.196
2.866.767
2.883.814
2.900.861
581
O-6-12-ii
3.412.269
3.442.980
3.463.453
3.483.927
582
O-6-12-iii
4.287.027
4.325.611
4.351.333
4.377.055
583
O-6-13-i
PERSALINAN VAGINAL RINGAN
2.038.994
2.057.345
2.069.579
2.081.813
584
O-6-13-ii
PERSALINAN VAGINAL SEDANG
2.413.860
2.435.585
2.450.068
2.464.551
585
O-6-13-iii
PERSALINAN VAGINAL BERAT
3.218.481
3.247.447
3.266.758
3.286.069
586
P-8-01-i
70.613.202
71.248.721
71.672.400
72.096.080

PEMASANGAN ALAT SALURAN URIN,
PEMINDAHAN KULIT ATAU PENCAKOKAN
(RINGAN)
(SEDANG)
(BERAT)
GEJALA, TANDA-TANDA PADA GINJAL DAN
SALURAN URIN RINGAN
SALURAN URIN SEDANG
SALURAN URIN BERAT
DIAGNOSIS GINJAL DAN SALURAN URIN LAINLAIN (RINGAN)
DIAGNOSIS GINJAL DAN SALURAN URIN LAINLAIN (SEDANG)
DIAGNOSIS GINJAL DAN SALURAN URIN LAINLAIN (BERAT)
PROSEDUR OPERASI PEMBEDAHAN CAESAR
RINGAN
SEDANG
BERAT
PROSEDUR PERSALINAN VAGINAL DENGAN
STERILISASI &/ DILATASI & KURET RINGAN
STERILISASI &/ DILATASI & KURET SEDANG
STERILISASI &/ DILATASI & KURET BERAT
PROSEDUR SELAIN STERILISASI &/ DILATASI
&KURET RINGAN
PROSEDUR SELAIN STERILISASI &/ DILATASI &
KURET SEDANG
KURET BERAT
PROSEDUR NEONATAL DENGAN

PENCANGKOKAN ORGAN ATAU OKSIGENASI
SELAPUT EKSTRAKORPORAL RINGAN
- 20 No
Kode
INA-CBG
587
P-8-01-ii
588
P-8-01-iii
589
P-8-02-i
590
P-8-02-ii
591
P-8-02-iii
592
P-8-03-i
593
P-8-03-ii
594
P-8-03-iii
595
P-8-04-i
596
P-8-04-ii
597
P-8-04-iii
598
P-8-05-i
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii
603
P-8-06-iii
604
P-8-07-i
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
Deskripsi (INA-CBG)
SELAPUT EKSTRAKORPORAL SEDANG
SELAPUT EKSTRAKORPORAL BERAT
PROSEDUR NEONATAL, BERAT BADAN LAHIR
GROUP-1 DENGAN PROSEDUR MAYOR RINGAN
GROUP-1 DENGAN PROSEDUR MAYOR SEDANG
GROUP-1 DENGAN PROSEDUR MAYOR BERAT
GROUP-1 TANPA PROSEDUR MAYOR RINGAN
GROUP-1 TANPA PROSEDUR MAYOR SEDANG
GROUP-1 TANPA PROSEDUR MAYOR BERAT
GROUP-5 DENGAN SINDROMA DISTRES
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
NEONATAL, MENINGGAL DAN DITRANSFER KE
FASILITAS PERAWATAN PASIEN AKUT LAIN
RINGAN
SEDANG
BERAT
NEONATAL, BBL GROUP-2 TANPA PROSEDUR
MAYOR RINGAN
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
87.372.792
88.159.147
88.683.384
89.207.621
102.551.165
103.474.125
104.089.432
104.704.739
77.171.267
77.865.809
78.328.836
78.791.864
88.523.387
89.320.097
89.851.238
90.382.378
101.144.299
102.054.598
102.661.464
103.268.329
4.732.287
4.774.878
4.803.271
4.831.665
6.625.202
6.684.829
6.724.580
6.764.331
10.436.196
10.530.122
10.592.739
10.655.356
38.121.943
38.465.041
38.693.772
38.922.504
49.474.063
49.919.329
50.216.174
50.513.018
70.933.353
71.571.753
71.997.353
72.422.954
20.729.477
20.916.042
21.040.419
21.164.796
29.381.238
29.645.670
29.821.957
29.998.244
43.289.311
43.678.914
43.938.650
44.198.386
3.785.830
3.819.902
3.842.617
3.865.332
8.592.811
8.670.146
8.721.703
8.773.260
15.983.609
16.127.461
16.223.363
16.319.264
6.625.202
6.684.829
6.724.580
6.764.331
18.575.471
18.742.651
18.854.103
18.965.556
24.607.893
24.829.364
24.977.011
25.124.659
4.330.767
4.369.744
4.395.728
4.421.713
6.148.133
6.203.466
6.240.355
6.277.243
8.679.275
8.757.389
8.809.464
8.861.540
2.686.803
2.710.984
2.727.105
2.743.226
3.892.225
3.927.255
3.950.608
3.973.961
7.641.584
7.710.358
7.756.208
7.802.057
7.565.310
7.633.398
7.678.790
7.724.182
- 21 No
Kode
INA-CBG
614
P-8-11-ii
615
P-8-11-iii
616
P-8-12-i
617
P-8-12-ii
618
P-8-12-iii
619
P-8-13-i
620
P-8-13-ii
621
P-8-13-iii
622
P-8-14-i
623
P-8-14-ii
624
P-8-14-iii
625
P-8-15-i
626
P-8-15-ii
627
P-8-15-iii
628
P-8-16-i
629
P-8-16-ii
630
P-8-16-iii
631
P-8-17-i
632
P-8-17-ii
633
P-8-17-iii
634
S-4-10-i
635
S-4-10-ii
636
S-4-10-iii
637
S-4-11-i
638
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
16.110.315
16.255.308
16.351.970
16.448.632
16.447.829
16.595.860
16.694.547
16.793.234
9.661.603
9.748.558
9.806.528
9.864.497
11.862.412
11.969.174
12.040.349
12.111.523
12.971.253
13.087.994
13.165.822
13.243.649
1.975.659
1.993.440
2.005.294
2.017.148
3.414.466
3.445.196
3.465.683
3.486.170
5.106.699
5.152.659
5.183.300
5.213.940
3.371.311
3.401.653
3.421.881
3.442.109
6.883.263
6.945.212
6.986.512
7.027.811
7.550.914
7.618.872
7.664.178
7.709.483
2.535.331
2.558.149
2.573.361
2.588.573
5.067.460
5.113.067
5.143.472
5.173.877
5.952.516
6.006.089
6.041.804
6.077.519
2.295.074
2.315.729
2.329.500
2.343.270
3.255.660
3.284.961
3.304.495
3.324.029
4.226.007
4.264.041
4.289.397
4.314.753
1.679.271
1.694.384
1.704.460
1.714.536
5.031.466
5.076.749
5.106.938
5.137.127
10.155.694
10.247.095
10.308.029
10.368.963
2.810.382
2.835.675
2.852.538
2.869.400
3.175.329
3.203.907
3.222.959
3.242.011
4.364.407
4.403.687
4.429.874
4.456.060
REAKSI ALLERGI RINGAN
1.644.445
1.659.245
1.669.111
1.678.978
S-4-11-ii
REAKSI ALLERGI SEDANG
2.411.480
2.433.184
2.447.653
2.462.121
639
S-4-11-iii
REAKSI ALLERGI BERAT
4.121.482
4.158.575
4.183.304
4.208.033
640
S-4-12-i
EFEK TOKSIK DAN KERACUNAN OBAT RINGAN
2.107.786
2.126.757
2.139.403
2.152.050
641
S-4-12-ii
EFEK TOKSIK DAN KERACUNAN OBAT SEDANG
2.810.382
2.835.675
2.852.538
2.869.400
642
S-4-12-iii
EFEK TOKSIK DAN KERACUNAN OBAT BERAT
5.488.898
5.538.298
5.571.232
5.604.165
643
S-4-13-i
2.810.382
2.835.675
2.852.538
2.869.400
644
S-4-13-ii
4.968.125
5.012.838
5.042.647
5.072.456
645
S-4-13-iii
10.115.734
10.206.776
10.267.470
10.328.165

MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
NEONATAL, BBL GROUP-5 DENGAN ANOMALI
MAYOR ATAU KONDISI HEREDITER RINGAN
MAYOR ATAU KONDISI HEREDITER SEDANG
MAYOR ATAU KONDISI HEREDITER BERAT
NEONATAL, BBL GROUP-5 DENGAN SINDROMA
ASPIRASI RINGAN
ASPIRASI SEDANG
ASPIRASI BERAT
NEONATAL, BBL GROUP-5 DENGAN
KONGENITAL/INFEKSI PERINATAL RINGAN
KONGENITAL/INFEKSI PERINATAL SEDANG
KONGENITAL/INFEKSI PERINATAL BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
KECEDERAAN PADA TEMPAT YANG TAK
SPESIFIK ATAU BANYAK TEMPAT (RINGAN)
SPESIFIK ATAU BANYAK TEMPAT (SEDANG)
SPESIFIK ATAU BANYAK TEMPAT (BERAT)
KOMPLIKASI DARI PENATALAKSANAAN

PASIEN RINGAN
PASIEN SEDANG
PASIEN BERAT
- 22 No
Kode
INA-CBG
646
S-4-14-i
647
S-4-14-ii
648
S-4-14-iii
649
S-4-15-i
650
S-4-15-ii
651
S-4-15-iii
652
S-4-16-i
653
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.712.314
1.727.725
1.737.999
1.748.273
3.637.529
3.670.267
3.692.092
3.713.917
6.898.052
6.960.134
7.001.522
7.042.911
1.295.039
1.306.694
1.314.464
1.322.235
2.444.179
2.466.177
2.480.842
2.495.507
3.165.780
3.194.272
3.213.267
3.232.262
LUKA BAKAR RINGAN
4.918.168
4.962.432
4.991.941
5.021.450
S-4-16-ii
LUKA BAKAR SEDANG
6.265.512
6.321.902
6.359.495
6.397.088
654
S-4-16-iii
LUKA BAKAR BERAT
11.188.045
11.288.738
11.355.866
11.422.994
655
S-4-17-i
2.365.527
2.386.816
2.401.009
2.415.203
656
S-4-17-ii
3.512.977
3.544.594
3.565.672
3.586.750
657
S-4-17-iii
5.728.603
5.780.160
5.814.532
5.848.904
658
T-1-10-i
2.441.876
2.463.853
2.478.504
2.493.156
659
T-1-10-ii
3.279.274
3.308.788
3.328.463
3.348.139
660
T-1-10-iii
5.966.069
6.019.763
6.055.560
6.091.356
661
T-4-10-i
1.184.166
1.194.823
1.201.928
1.209.033
662
T-4-10-ii
2.256.757
2.277.068
2.290.608
2.304.149
663
T-4-10-iii
3.280.712
3.310.238
3.329.923
3.349.607
664
T-4-11-i
1.056.336
1.065.843
1.072.181
1.078.519
665
T-4-11-ii
1.662.372
1.677.333
1.687.307
1.697.281
666
T-4-11-iii
2.677.591
2.701.689
2.717.755
2.733.820
667
T-4-12-i
2.459.084
2.481.216
2.495.970
2.510.725
668
T-4-12-ii
3.716.770
3.750.221
3.772.522
3.794.823
669
T-4-12-iii
5.781.959
5.833.997
5.868.689
5.903.380
670
U-1-10-i
PROSEDUR KOMPLEKS LARING RINGAN
2.617.470
2.641.027
2.656.732
2.672.437
671
U-1-10-ii
PROSEDUR KOMPLEKS LARING SEDANG
5.341.108
5.389.178
5.421.225
5.453.271
672
U-1-10-iii
PROSEDUR KOMPLEKS LARING BERAT
23.063.983
23.271.559
23.409.943
23.548.327
673
U-1-11-i
11.357.489
11.459.706
11.527.851
11.595.996
674
U-1-11-ii
15.143.319
15.279.608
15.370.468
15.461.328
675
U-1-11-iii
22.949.418
23.155.963
23.293.660
23.431.356
SINDROMA MALTREATMENT PADA DEWASA

ATAU KANAK-KANAK RINGAN
ATAU KANAK-KANAK SEDANG
ATAU KANAK-KANAK BERAT
LUKA BAKAR, DIRUJUK KE FASILITAS
PERAWATAN AKUT YANG LAIN (RINGAN)
PERAWATAN AKUT YANG LAIN (SEDANG)
PERAWATAN AKUT YANG LAIN (BERAT)
DIAGNOSIS KECEDERAAN, KERACUNAN DAN

EFEK TOKSIK LAIN-LAIN RINGAN
EFEK TOKSIK LAIN-LAIN SEDANG
EFEK TOKSIK LAIN-LAIN BERAT
TERAPI REHABILITASI &/ DETOKSIKASI
ALKOHOL & OBAT RINGAN
ALKOHOL & OBAT SEDANG
ALKOHOL & OBAT BERAT
PENYALAHGUNAAN & KETERGANTUNGAN
OBAT DAN ALKOHOL, MENOLAK NASEHAT
DOKTER RINGAN
DOKTER SEDANG
DOKTER BERAT
ALKOHOL,OPIUM DAN KOKAIN RINGAN
ALKOHOL,OPIUM DAN KOKAIN SEDANG
ALKOHOL,OPIUM DAN KOKAIN BERAT
OBAT LAIN-LAIN (RINGAN)
OBAT LAIN-LAIN (SEDANG)
OBAT LAIN-LAIN (BERAT)
PROSEDUR KOMPLEK LEHER DAN KEPALA

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
- 23 No
Kode
INA-CBG
676
U-1-12-i
677
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
PROSEDUR MASTOID DAN SINUS RINGAN
6.260.667
6.317.013
6.354.577
6.392.141
U-1-12-ii
PROSEDUR MASTOID DAN SINUS SEDANG
17.036.233
17.189.560
17.291.777
17.393.994
678
U-1-12-iii
PROSEDUR MASTOID DAN SINUS BERAT
22.121.872
22.320.968
22.453.700
22.586.431
679
U-1-13-i
PROSEDUR KELENJAR LUDAH RINGAN
7.185.405
7.250.073
7.293.186
7.336.298
680
U-1-13-ii
PROSEDUR KELENJAR LUDAH SEDANG
7.705.892
7.775.246
7.821.481
7.867.716
681
U-1-13-iii
15.617.935
15.758.496
15.852.204
15.945.912
3.768.481
3.802.397
3.825.008
3.847.619
4.624.684
4.666.306
4.694.054
4.721.803
5.480.381
5.529.704
5.562.587
5.595.469
PROSEDUR KELENJAR LUDAH BERAT

PROSEDUR OPERASI BIBIR SUMBING & LANGITLANGIT MULUT (RINGAN)
PROSEDUR OPERASI BIBIR SUMBING & LANGITLANGIT MULUT (SEDANG)
PROSEDUR OPERASI BIBIR SUMBING & LANGITLANGIT MULUT (BERAT)
682
U-1-14-i
683
U-1-14-ii
684
U-1-14-iii
685
U-1-15-i
PROSEDUR TONSIL & ADENOID RINGAN
2.213.373
2.233.293
2.246.573
2.259.853
686
U-1-15-ii
PROSEDUR TONSIL & ADENOID SEDANG
3.145.048
3.173.353
3.192.224
3.211.094
687
U-1-15-iii
PROSEDUR TONSIL & ADENOID BERAT
6.197.443
6.253.220
6.290.405
6.327.590
688
U-1-20-i
5.725.031
5.776.556
5.810.906
5.845.257
689
U-1-20-ii
10.190.555
10.282.270
10.343.414
10.404.557
690
U-1-20-iii
26.504.557
26.743.098
26.902.125
27.061.152
691
U-1-30-i
PROSEDUR MULUT RINGAN
4.911.078
4.955.278
4.984.744
5.014.211
692
U-1-30-ii
PROSEDUR MULUT SEDANG
6.629.956
6.689.625
6.729.405
6.769.185
693
U-1-30-iii
PROSEDUR MULUT BERAT
12.996.619
13.113.589
13.191.569
13.269.548
694
U-4-10-i
4.571.393
4.612.536
4.639.964
4.667.393
695
U-4-10-ii
11.459.523
11.562.659
11.631.416
11.700.173
696
U-4-10-iii
16.716.949
16.867.402
16.967.704
17.068.005
697
U-4-11-i
DYSEQUILIBRIUM RINGAN
2.810.382
2.835.675
2.852.538
2.869.400
698
U-4-11-ii
DYSEQUILIBRIUM SEDANG
4.172.254
4.209.804
4.234.837
4.259.871
699
U-4-11-iii
DYSEQUILIBRIUM BERAT
5.258.911
5.306.242
5.337.795
5.369.348
700
U-4-12-i
EPISTAKSIS/PERDARAHAN HIDUNG RINGAN
2.543.884
2.566.778
2.582.042
2.597.305
701
U-4-12-ii
EPISTAKSIS/PERDARAHAN HIDUNG SEDANG
2.955.265
2.981.862
2.999.594
3.017.325
702
U-4-12-iii
EPISTAKSIS/PERDARAHAN HIDUNG BERAT
4.698.737
4.741.026
4.769.218
4.797.410
703
U-4-13-i
2.490.483
2.512.898
2.527.841
2.542.784
704
U-4-13-ii
2.941.411
2.967.884
2.985.533
3.003.181
705
U-4-13-iii
3.512.977
3.544.594
3.565.672
3.586.750
706
U-4-14-i
PENYAKIT MULUT DAN GIGI RINGAN
3.512.977
3.544.594
3.565.672
3.586.750
707
U-4-14-ii
PENYAKIT MULUT DAN GIGI SEDANG
4.215.573
4.253.513
4.278.806
4.304.100
708
U-4-14-iii
PENYAKIT MULUT DAN GIGI BERAT
7.061.816
7.125.372
7.167.743
7.210.114
PROSEDUR TENGGOROKAN, MULUT, HIDUNG

DAN TELINGA LAIN-LAIN (RINGAN)
DAN TELINGA LAIN-LAIN (SEDANG)
DAN TELINGA LAIN-LAIN (BERAT)
TUMOR KERONGKONGAN, MULUT, HIDUNG

DAN TELINGA RINGAN
DAN TELINGA SEDANG
DAN TELINGA BERAT
PERADANGAN EPIGLOTIS, TELINGA TENGAH,

ISPA DAN LARINGOTRAKEITIS RINGAN
ISPA DAN LARINGOTRAKEITIS SEDANG
ISPA DAN LARINGOTRAKEITIS BERAT
- 24 No
Kode
INA-CBG
709
U-4-15-i
710
U-4-15-ii
711
U-4-15-iii
712
V-1-10-i
713
V-1-10-ii
714
V-1-10-iii
715
V-1-11-i
716
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.810.382
2.835.675
2.852.538
2.869.400
3.512.977
3.544.594
3.565.672
3.586.750
4.919.122
4.963.394
4.992.909
5.022.423
8.215.678
8.289.619
8.338.913
8.388.207
9.464.574
9.549.755
9.606.543
9.663.330
17.463.244
17.620.413
17.725.193
17.829.972
PROSEDUR PADA PENIS RINGAN
8.735.078
8.813.693
8.866.104
8.918.514
V-1-11-ii
PROSEDUR PADA PENIS SEDANG
9.974.685
10.064.457
10.124.305
10.184.153
717
V-1-11-iii
PROSEDUR PADA PENIS BERAT
15.641.628
15.782.403
15.876.253
15.970.103
718
V-1-12-i
4.610.817
4.652.314
4.679.979
4.707.644
719
V-1-12-ii
17.621.008
17.779.597
17.885.323
17.991.049
720
V-1-12-iii
20.574.133
20.759.300
20.882.745
21.006.189
721
V-1-13-i
6.988.503
7.051.400
7.093.331
7.135.262
722
V-1-13-ii
13.280.162
13.399.683
13.479.364
13.559.045
723
V-1-13-iii
22.698.007
22.902.289
23.038.477
23.174.665
724
V-1-14-i
8.424.722
8.500.544
8.551.093
8.601.641
725
V-1-14-ii
12.253.036
12.363.313
12.436.832
12.510.350
726
V-1-14-iii
16.656.220
16.806.126
16.906.064
17.006.001
727
V-1-15-i
PROSEDUR SIRKUMSISI RINGAN
3.971.787
4.007.533
4.031.364
4.055.195
728
V-1-15-ii
PROSEDUR SIRKUMSISI SEDANG
7.565.482
7.633.571
7.678.964
7.724.357
729
V-1-15-iii
PROSEDUR SIRKUMSISI BERAT
14.206.371
14.334.228
14.419.466
14.504.704
730
V-4-10-i
6.395.580
6.453.140
6.491.514
6.529.887
731
V-4-10-ii
8.260.656
8.335.002
8.384.566
8.434.130
732
V-4-10-iii
15.787.563
15.929.651
16.024.376
16.119.102
733
V-4-11-i
3.512.977
3.544.594
3.565.672
3.586.750
734
V-4-11-ii
4.918.168
4.962.432
4.991.941
5.021.450
735
V-4-11-iii
7.840.922
7.911.490
7.958.535
8.005.581
736
W-1-01-i
9.563.625
9.649.698
9.707.080
9.764.462
737
W-1-01-ii
11.518.933
11.622.603
11.691.717
11.760.831
738
W-1-01-iii
25.443.035
25.672.022
25.824.680
25.977.339
739
W-1-10-i
PROSEDUR ABORSI RINGAN
2.663.458
2.687.429
2.703.410
2.719.391
740
W-1-10-ii
PROSEDUR ABORSI SEDANG
4.970.450
5.015.184
5.045.007
5.074.829
DIAGNOSIS TENGGOROKAN, MULUT, HIDUNG

& TELINGA LAIN-LAIN (RINGAN)
& TELINGA LAIN-LAIN (SEDANG)
& TELINGA LAIN-LAIN (BERAT)
PROSEDUR PENGANGKATAN PROSTAT
KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT
PROSEDUR PADA SKROTUM DAN PROSTAT

KOMPLEK-MODERAT (RINGAN)
KOMPLEK-MODERAT (SEDANG)
KOMPLEK-MODERAT (BERAT)
NON KOMPLEK (RINGAN)
NON KOMPLEK (SEDANG)
NON KOMPLEK (BERAT)
MELALUI URETRA RINGAN
MELALUI URETRA SEDANG
MELALUI URETRA BERAT
TUMOR PADA SISTEM REPRODUKSI LAKI-LAKI

RINGAN
SEDANG
BERAT
DIAGNOSIS SISTEM REPRODUKSI LAKI-LAKI
SELAIN TUMOR (RINGAN)
SELAIN TUMOR (SEDANG)
SELAIN TUMOR (BERAT)
PROSEDUR OPERASI PENGANGKATAN RAHIM
DAN VULVA RADIKAL & EVISCERASI RINGAN
DAN VULVA RADIKAL & EVISCERASI SEDANG
DAN VULVA RADIKAL & EVISCERASI BERAT
- 25 No
Kode
INA-CBG
741
W-1-10-iii
Deskripsi (INA-CBG)
PROSEDUR ABORSI BERAT
PROSEDUR DILATASI, KURET, INTRAUTERIN &
SERVIK RINGAN
SERVIK SEDANG
SERVIK BERAT
PROSEDUR OPERASI MEMBUKA TUBA YANG
TERHALANG/TERGANGGU RINGAN
TERHALANG/TERGANGGU SEDANG
TERHALANG/TERGANGGU BERAT
PROSEDUR INTERUPSI TUBA DENGAN
ENDOSKOP RINGAN
ENDOSKOP SEDANG
ENDOSKOP BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
8.130.079
8.203.250
8.252.030
8.300.811
2.766.447
2.791.345
2.807.944
2.824.543
5.335.444
5.383.463
5.415.475
5.447.488
11.104.147
11.204.084
11.270.709
11.337.334
2.513.733
2.536.357
2.551.439
2.566.522
2.858.066
2.883.789
2.900.937
2.918.086
4.390.350
4.429.863
4.456.206
4.482.548
3.316.913
3.346.765
3.366.666
3.386.568
3.601.211
3.633.622
3.655.229
3.676.837
4.837.091
4.880.625
4.909.648
4.938.670
742
W-1-11-i
743
W-1-11-ii
744
W-1-11-iii
745
W-1-12-i
746
W-1-12-ii
747
W-1-12-iii
748
W-1-13-i
749
W-1-13-ii
750
W-1-13-iii
751
W-1-20-i
PROSEDUR PADA RAHIM & ADNEKSA RINGAN
8.152.175
8.225.544
8.274.457
8.323.370
752
W-1-20-ii
PROSEDUR PADA RAHIM & ADNEKSA SEDANG
11.467.257
11.570.462
11.639.266
11.708.069
753
W-1-20-iii
PROSEDUR PADA RAHIM & ADNEKSA BERAT
14.486.378
14.616.755
14.703.673
14.790.592
754
W-1-30-i
4.450.270
4.490.322
4.517.024
4.543.726
755
W-1-30-ii
7.098.411
7.162.296
7.204.887
7.247.477
756
W-1-30-iii
18.876.421
19.046.309
19.159.567
19.272.826
757
W-4-10-i
TUMOR SISTEM REPRODUKSI WANITA RINGAN
3.318.786
3.348.655
3.368.568
3.388.481
758
W-4-10-ii
TUMOR SISTEM REPRODUKSI WANITA SEDANG
4.918.168
4.962.432
4.991.941
5.021.450
759
W-4-10-iii
TUMOR SISTEM REPRODUKSI WANITA BERAT
11.241.528
11.342.701
11.410.151
11.477.600
760
W-4-11-i
INFEKSI SISTEM REPRODUKSI WANITA RINGAN
3.512.977
3.544.594
3.565.672
3.586.750
761
W-4-11-ii
INFEKSI SISTEM REPRODUKSI WANITA SEDANG
5.620.764
5.671.351
5.705.075
5.738.800
762
W-4-11-iii
INFEKSI SISTEM REPRODUKSI WANITA BERAT
6.830.894
6.892.372
6.933.357
6.974.343
763
W-4-12-i
2.810.382
2.835.675
2.852.538
2.869.400
764
W-4-12-ii
3.864.275
3.899.054
3.922.239
3.945.425
765
W-4-12-iii
4.215.573
4.253.513
4.278.806
4.304.100
766
W-4-13-i
ABORTUS RINGAN
1.541.247
1.555.118
1.564.365
1.573.613
767
W-4-13-ii
ABORTUS SEDANG
2.107.786
2.126.757
2.139.403
2.152.050
768
W-4-13-iii
ABORTUS BERAT
2.622.932
2.646.539
2.662.276
2.678.014
769
W-4-14-i
ABORTUS MENGANCAM RINGAN
2.056.139
2.074.645
2.086.981
2.099.318
770
W-4-14-ii
ABORTUS MENGANCAM SEDANG
2.445.347
2.467.355
2.482.027
2.496.699
771
W-4-14-iii
ABORTUS MENGANCAM BERAT
3.123.631
3.151.744
3.170.486
3.189.228
772
W-4-15-i
PERSALINAN FALSE LABOR RINGAN
1.585.442
1.599.711
1.609.224
1.618.736
773
W-4-15-ii
PERSALINAN FALSE LABOR SEDANG
1.763.314
1.779.183
1.789.763
1.800.343
PROSEDUR PADA VAGINA, SERVIK & VULVA

RINGAN
SEDANG
BERAT
GANGGUAN MENSTRUASI & SISTEM

REPRODUKSI WANITA LAIN-LAIN (RINGAN)
REPRODUKSI WANITA LAIN-LAIN (SEDANG)
REPRODUKSI WANITA LAIN-LAIN (BERAT)
- 26 No
Kode
INA-CBG
774
W-4-15-iii
775
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
PERSALINAN FALSE LABOR BERAT
2.441.475
2.463.448
2.478.097
2.492.746
W-4-16-i
GANGGUAN ANTEPARTUM RINGAN
2.107.786
2.126.757
2.139.403
2.152.050
776
W-4-16-ii
GANGGUAN ANTEPARTUM SEDANG
2.810.382
2.835.675
2.852.538
2.869.400
777
W-4-16-iii
GANGGUAN ANTEPARTUM BERAT
3.831.573
3.866.058
3.889.047
3.912.036
778
W-4-17-i
GANGGUAN POSTPARTUM RINGAN
1.552.877
1.566.853
1.576.170
1.585.488
779
W-4-17-ii
GANGGUAN POSTPARTUM SEDANG
2.810.382
2.835.675
2.852.538
2.869.400
780
W-4-17-iii
GANGGUAN POSTPARTUM BERAT
5.316.684
5.364.534
5.396.434
5.428.334
781
Z-4-10-i
REHABILITASI RINGAN
4.822.283
4.865.683
4.894.617
4.923.551
782
Z-4-10-ii
REHABILITASI SEDANG
6.400.884
6.458.492
6.496.897
6.535.303
783
Z-4-10-iii
REHABILITASI BERAT
9.093.066
9.174.904
9.229.462
9.284.021
784
Z-4-11-i
GEJALA-GEJALA DAN TANDA-TANDA RINGAN
3.796.912
3.831.084
3.853.865
3.876.647
785
Z-4-11-ii
GEJALA-GEJALA DAN TANDA-TANDA SEDANG
4.570.642
4.611.778
4.639.202
4.666.626
786
Z-4-11-iii
GEJALA-GEJALA DAN TANDA-TANDA BERAT
8.017.042
8.089.196
8.137.298
8.185.400
787
Z-4-12-i
2.107.786
2.126.757
2.139.403
2.152.050
788
Z-4-12-ii
4.215.573
4.253.513
4.278.806
4.304.100
789
Z-4-12-iii
4.922.968
4.967.274
4.996.812
5.026.350
FAKTOR-FAKTOR YANG MEMPENGARUHI

STATUS KESEHATAN LAIN-LAIN (RINGAN)
STATUS KESEHATAN LAIN-LAIN (SEDANG)
STATUS KESEHATAN LAIN-LAIN (BERAT)
2. RawatJalan
No
Kode
INA-CBG
B-2-10-0
B-2-11-0
- 27 -
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
PROSEDUR PADA HATI DAN PANKREAS
1.376.712
1.389.103
1.397.363
1.405.623
PROSEDUR BESAR PADA SALURAN EMPEDU
1.785.811
1.801.883
1.812.598
1.823.313
3.320.951
3.350.840
3.370.765
3.390.691
2.744.444
2.769.144
2.785.610
2.802.077
2.292.746
2.313.381
2.327.137
2.340.894
803.847
811.082
815.905
820.728
1.792.473
1.808.606
1.819.360
1.830.115
368.294
371.609
373.819
376.029
PROSEDUR KOLESISTEKTOMI TANPA

LAPAROSKOPI
PROSEDUR LAIN-LAIN PADA HEPATOBILIARI &
PANKREAS
PROSEDUR KOLESISTEKTOMI DENGAN
LAPAROSKOPI
PROSEDUR PADA PERKUTAN HATI & SALURAN
EMPEDU
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
PROSEDUR ENDOSKOPI SALURAN EMPEDU
B-3-12-0
PROSEDUR LAIN-LAIN PADA SISTEM

HEPATOBILIARI DAN PANKREAS
C-3-10-0
PROSEDUR RADIOTERAPI
1.004.655
1.013.697
1.019.725
1.025.752
10
C-3-11-0
KEMOTERAPI PADA TUMOR PARU &

KANDUNG KEMIH
1.588.900
1.603.200
1.612.733
1.622.266
11
C-3-12-0
KEMOTERAPI PADA TUMOR KOLON
360.200
363.442
365.603
367.764
12
C-3-13-0
349.779
352.927
355.026
357.124
13
C-3-14-0
2.977.675
3.004.474
3.022.340
3.040.206
14
C-3-15-0
2.729.158
2.753.720
2.770.095
2.786.470
15
C-3-16-0
KEMOTERAPI PADA TUMOR OTAK
618.907
624.477
628.191
631.904
16
C-3-17-0
KEMOTERAPI PADA TUMOR KEPALA ATAU

LEHER
410.565
414.260
416.723
419.187
17
C-3-18-0
KEMOTERAPI PADA LEUKEMIA AKUT
182.027
183.665
184.757
185.849
18
C-3-19-0
KEMOTERAPI PADA TUMOR LIMFOMA,

MYELOMA ATAU TESTIS
257.423
259.740
261.284
262.829
19
C-3-20-0
KEMOTERAPI PADA TUMOR KULIT
5.126.584
5.172.724
5.203.483
5.234.243
20
C-3-21-0
KEMOTERAPI PADA TUMOR GINEKOLOGI
293.765
296.409
298.172
299.935
21
C-3-22-0
KEMOTERAPI PADA TUMOR METASTASE
1.289.787
1.301.395
1.309.134
1.316.872
22
C-3-23-0
KEMOTERAPI PADA TUMOR LAIN-LAIN
208.917
210.798
212.051
213.305
23
D-2-10-0

TULANG
1.769.977
1.785.907
1.796.526
1.807.146
24
D-2-11-0
PROSEDUR LIMPA
2.216.313
2.236.260
2.249.558
2.262.856
25
D-2-21-0
1.858.859
1.875.589
1.886.742
1.897.895
26
D-2-22-0
407.964
411.635
414.083
416.531
27
D-3-10-0
295.498
298.158
299.931
301.704
28
D-3-11-0
767.198
774.103
778.706
783.309
29
E-2-10-0
455.096
459.192
461.923
464.653
30
E-2-21-0
329.929
332.899
334.878
336.858
31
E-2-22-0
329.929
332.899
334.878
336.858
KEMOTERAPI PADA TUMOR PAYUDARA ATAU

OVARIUM
KEMOTERAPI PADA TUMOR
GASTROINTESTINAL
KEMOTERAPI PADA TUMOR MELANOMA,
GINJAL ATAU PROSTAT
PROSEDUR BESAR PADA NODUL LIMPA DAN

TYMUS
PROSEDUR KECIL PADA NODUL LIMPA DAN
TYMUS
PROSEDUR TRANSFUSI & TERAPI SUMSUM
TULANG
PROSEDUR DIAGNOSTIK DARAH DAN ORGAN
PEMBENTUK DARAH
PROSEDUR PADA KELENJAR ADRENAL
PROSEDUR BESAR PADA KELENJAR TIROID DAN
PARATIROID
PROSEDUR KECIL PADA KELENJAR
TIROID,PARATIROID DAN SALURAN
THYROGLOSSAL
- 28 No
Kode
INA-CBG
32
E-3-10-0
33
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
PROSEDUR DIAGNOSTIK PADA KELENJAR

ENDOKRIN
383.686
387.139
389.442
391.744
F-3-10-0
TERAPI SHOCK
535.230
540.047
543.258
546.470
34
F-5-10-0
PELAYANAN KESEHATAN MENTAL EKSTENSIF
655.830
661.732
665.667
669.602
35
F-5-11-0
TERAPI KELOMPOK
432.460
436.352
438.946
441.541
36
F-5-12-0
PROSEDUR TES DIAGNOSTIK KESEHATAN JIWA
553.405
558.386
561.706
565.027
37
F-5-13-0
PSIKOTERAPI INDIVIDU DEWASA AKUT
468.698
472.916
475.728
478.540
38
F-5-14-0
314.433
317.263
319.150
321.037
39
F-5-15-0
294.979
297.634
299.404
301.174
40
F-5-16-0
307.249
310.014
311.858
313.701
41
G-2-10-0
258.727
261.056
262.608
264.161
42
G-2-11-0
PROSEDUR SHUNT VENTRIKEL
2.242.757
2.262.942
2.276.398
2.289.855
43
G-2-12-0
PROSEDUR PADA PEMBULUH DARAH

EKSTRAKRANIAL
3.250.307
3.279.560
3.299.061
3.318.563
44
G-2-13-0
PROSEDUR CARPAL TUNNEL RELEASE
797.373
804.549
809.333
814.118
45
G-2-21-0
PROSEDUR BESAR PADA SARAF PERIFER
1.454.274
1.467.362
1.476.088
1.484.813
46
G-2-22-0
PROSEDUR KECIL PADA SARAF PERIFER
1.319.877
1.331.756
1.339.675
1.347.594
47
G-2-31-0
PROSEDUR BESAR PADA TULANG BELAKANG
2.177.912
2.197.513
2.210.580
2.223.648
48
G-2-32-0
PROSEDUR KECIL PADA TULANG BELAKANG
1.116.396
1.126.443
1.133.142
1.139.840
49
G-3-10-0
PROSEDUR TAP & INJEKSI PADA SPINAL
443.105
447.093
449.751
452.410
50
G-3-11-0
PROSEDUR INJEKSI PADA SARAF PERIFER
590.130
595.441
598.982
602.523
51
G-3-12-0
PROSEDUR PEMERIKSAAN NEUROLOGIS LAIN
966.939
975.641
981.443
987.244
52
G-3-13-0
PROSEDUR ELEKROENSEFALOGRAFI (EEG)
967.049
975.752
981.555
987.357
53
H-2-21-0
PROSEDUR BESAR PADA MATA
1.269.108
1.280.530
1.288.145
1.295.759
54
H-2-22-0
PROSEDUR SEDANG PADA MATA
329.929
332.899
334.878
336.858
55
H-2-23-0
PROSEDUR KECIL PADA MATA
329.929
332.899
334.878
336.858
56
H-2-31-0
2.102.172
2.121.092
2.133.705
2.146.318
57
H-2-32-0
218.787
220.756
222.069
223.382
58
H-2-33-0
329.929
332.899
334.878
336.858
59
H-2-34-0
943.086
951.573
957.232
962.890
60
H-2-35-0
310.768
313.565
315.430
317.294
61
H-2-36-0
PROSEDUR OPERASI KATARAK
1.677.454
1.692.551
1.702.615
1.712.680
62
H-2-37-0
PROSEDUR PHOTOKOAGULASI DAN

KRIOTHERAPI PADA RETINA
1.785.723
1.801.795
1.812.509
1.823.223
63
H-3-10-0
PROSEDUR LASER SEDANG PADA MATA
621.301
626.893
630.621
634.348
64
H-3-11-0
PROSEDUR KECIL PADA EKTRAOKULER
326.736
329.676
331.637
333.597
PSIKOTHERAPI INDIVIDU DEWASA BUKAN

AKUT
PENGOBATAN INDIVIDU KETERBELAKANGAN
MENTAL
PSIKOTHERAPI INDIVIDU PADA KANAKKANAK MASALAH KESEHATAN MENTAL
PROSEDUR KRANIOTOMI
PROSEDUR BESAR PADA SEGMEN ANTERIOR

MATA
PROSEDUR SEDANG PADA SEGMEN ANTERIOR
MATA
PROSEDUR KECIL PADA SEGMEN ANTERIOR
MATA
PROSEDUR BESAR PADA SEGMEN POSTERIOR
MATA
PROSEDUR KECIL PADA SEGMEN POSTERIOR
MATA
- 29 No
Kode
INA-CBG
65
H-3-12-0
66
H-3-13-0
67
I-2-11-0
68
I-2-12-0
69
I-2-13-0
70
I-2-14-0
71
I-2-15-0
Deskripsi (INA-CBG)
PROSEDUR LAIN-LAIN PADA MATA
PROSEDUR DIAGNOSTIK & IMAGING PADA
MATA
PEMASANGAN/PENYISIPAN DEFIBRILATOR
JANTUNG & SISTEM BANTU JANTUNG
PROSEDUR BESAR PADA PEMBULUH DARAH
TORASIK
ABDOMEN
PROSEDUR PEMASANGAN/PENYISIPAN ALAT
PACU PERMANEN PADA JANTUNG
PROSEDUR KATETERISASI JANTUNG
PROSEDUR REVISI DEFIBRILATOR DAN ALAT
PACU JANTUNG TIDAK TERMASUK
PENGGANTIAN ALAT
DARAH VENA
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
341.129
344.199
346.246
348.292
331.215
334.196
336.184
338.171
3.819.618
3.853.995
3.876.912
3.899.830
2.685.608
2.709.779
2.725.892
2.742.006
3.413.247
3.443.966
3.464.445
3.484.925
6.040.720
6.095.086
6.131.330
6.167.575
363.277
366.547
368.726
370.906
3.815.479
3.849.818
3.872.711
3.895.604
1.257.854
1.269.174
1.276.722
1.284.269
72
I-2-16-0
73
I-2-17-0
74
I-2-21-0
ANGIOGRAFI ARTERI BUKAN JANTUNG
2.945.007
2.971.512
2.989.182
3.006.852
75
I-2-22-0
PROSEDUR SEDANG PADA PEMBULUH DARAH
2.773.240
2.798.199
2.814.839
2.831.478
76
I-2-23-0
PROSEDUR KECIL PADA PEMBULUH DARAH
567.535
572.643
576.048
579.453
77
I-2-31-0
4.413.913
4.453.639
4.480.122
4.506.606
78
I-2-32-0
5.771.840
5.823.786
5.858.417
5.893.048
79
I-2-41-0
PROSEDUR ELEKTROFISIOLOGIK
3.870.090
3.904.920
3.928.141
3.951.361
80
I-2-42-0
PROSEDUR ANGIOPLASTI PEMBULUH DARAH

KORONER DAN KARDIOVASKULAR PERKUTAN
LAIN
4.499.619
4.540.116
4.567.114
4.594.111
81
I-3-10-0
PROSEDUR RESUSITASI
571.187
576.327
579.754
583.182
82
I-3-11-0
PROSEDUR KARDIOVERSI
301.471
304.184
305.993
307.802
83
I-3-12-0
PROSEDUR KECIL LAIN-LAIN PADA JANTUNG
1.752.036
1.767.804
1.778.316
1.788.829
84
I-3-13-0
PROSEDUR EKOKARDIOGRAFI
575.436
580.615
584.068
587.521
85
I-3-14-0
PROSEDUR STRESS TESTING
368.835
372.155
374.368
376.581
PEMASANGAN ATAU PENGGANTIAN ALAT

DEFIBRILATOR JANTUNG
PACU JANTUNG
PROSEDUR PENGAWASAN FUNGSI

KARDIOVASKULAR
PROSEDUR BESAR PADA SISTEM SALURAN
PERNAFASAN
PROSEDUR VENTILASI MEKANIKAL JANGKA
PENDEK
326.736
329.676
331.637
333.597
2.022.936
2.041.143
2.053.280
2.065.418
326.097
329.032
330.988
332.945
86
I-3-15-0
87
J-2-10-0
88
J-2-21-0
89
J-2-22-0
PROSEDUR PADA LARING DAN TRAKEA
1.643.325
1.658.115
1.667.975
1.677.835
90
J-2-31-0
PROSEDUR
THORAKOSKOPI/MEDIASTINOSKOPI
2.131.540
2.150.723
2.163.513
2.176.302
91
J-2-32-0
PROSEDUR DADA INTERMEDIATE
1.586.219
1.600.495
1.610.013
1.619.530
92
J-3-10-0
PROSEDUR PADA DINDING DADA
329.929
332.899
334.878
336.858
93
J-3-11-0
PROSEDUR PEMASANGAN/PENYISIPAN TUBE

PADA DADA
932.321
940.712
946.306
951.900
94
J-3-12-0
PROSEDUR THORACENTESIS
360.200
363.442
365.603
367.764
95
J-3-13-0
PROSEDUR TERAPI SALURAN PERNAFASAN
530.125
534.896
538.077
541.258
96
J-3-14-0
PROSEDUR BIOPSI PERKUTAN DAN ASPIRASI
562.785
567.850
571.227
574.604
- 30 No
Kode
INA-CBG
97
J-3-15-0
98
J-3-16-0
99
J-3-17-0
100
K-2-10-0
101
K-2-11-0
102
K-2-12-0
103
K-2-13-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
PROSEDUR BRONKOSKOPI
493.518
497.959
500.920
503.882
PROSEDUR UJI FUNGSI PARU
562.785
567.850
571.227
574.604
329.929
332.899
334.878
336.858
949.649
958.196
963.894
969.592
PROSEDUR ADHESIOLYSIS PADA PERITONEUM
2.027.888
2.046.139
2.058.307
2.070.474
PROSEDUR PADA HERNIA TIDAK TERMASUK

HERNIA INGUINALIS DAN FEMORALIS
1.556.666
1.570.676
1.580.016
1.589.356
PROSEDUR PADA USUS BUNTU
2.533.558
2.556.360
2.571.561
2.586.763
329.929
332.899
334.878
336.858
PROSEDUR LAIN-LAIN PADA SISTEM SALURAN

PERNAFASAN
PROSEDUR KECIL PADA USUS BESAR DAN
KECIL
PROSEDUR PADA HERNIA INGUINALIS DAN

FEMORALIS
PROSEDUR BESAR PADA USUS HALUS DAN
USUS BESAR
PROSEDUR BESAR PADA GASTROINTESTINAL
ATAS
PROSEDUR SEDANG PADA GASTROINTESTINAL
ATAS
PROSEDUR LAIN-LAIN PADA
GASTROINTESTINAL ATAS
329.929
332.899
334.878
336.858
4.240.376
4.278.539
4.303.981
4.329.424
1.425.823
1.438.655
1.447.210
1.455.765
329.929
332.899
334.878
336.858
1.570.573
1.584.708
1.594.132
1.603.555
448.732
452.771
455.463
458.156
1.040.757
1.050.124
1.056.368
1.062.613
104
K-2-14-0
105
K-2-21-0
106
K-2-22-0
107
K-2-31-0
108
K-2-32-0
109
K-2-41-0
PROSEDUR LAPAROSKOPI
110
K-2-42-0
PROSEDUR LAPAROTOMI &

GASTROINTESTINAL LAINNYA
111
K-2-51-0
PROSEDUR UNTUK WASIR
112
K-2-52-0
PROSEDUR SEDANG PADA ANUS & REKTUM
567.535
572.643
576.048
579.453
113
K-2-53-0
PROSEDUR KECIL PADA ANUS & REKTUM
329.929
332.899
334.878
336.858
114
K-3-10-0
PROSEDUR KECIL LAIN-LAIN PADA

GASTROINTESTINAL
627.833
633.484
637.251
641.018
115
K-3-11-0
377.450
380.847
383.112
385.377
116
K-3-12-0
PROSEDUR SIGMOIDOSKOPI DAN ANOSKOPI
382.782
386.227
388.524
390.821
117
K-3-13-0
PROSEDUR KOLONOSKOPI
329.929
332.899
334.878
336.858
884.218
892.176
897.481
902.786
427.001
430.844
433.406
435.968
PROSEDUR ENDOSKOPI BESAR PADA

PROSEDUR ENDOSKOPI KECIL PADA
GASTROINTESTINAL
PROSEDUR BESAR PEMINDAHAN KULIT PADA
LUKA BAKAR
PROSEDUR KECIL PEMINDAHAN KULIT PADA
LUKA BAKAR
PROSEDUR BESAR PEMINDAHAN KULIT TANPA
LUKA BAKAR
PROSEDUR KECIL PEMINDAHAN KULIT TANPA
LUKA BAKAR
565.803
570.896
574.290
577.685
1.945.253
1.962.760
1.974.432
1.986.103
1.246.893
1.258.115
1.265.597
1.273.078
562.785
567.850
571.227
574.604
567.535
572.643
576.048
579.453
1.699.417
1.714.712
1.724.908
1.735.105
381.152
384.582
386.869
389.156
118
K-3-14-0
119
K-3-15-0
120
K-3-16-0
121
L-2-21-0
122
L-2-22-0
123
L-2-31-0
124
L-2-32-0
125
L-2-41-0
PROSEDUR BEDAH PLASTIK
126
L-2-42-0
PROSEDUR LAIN-LAIN PADA KULIT DAN

JARINGAN BAWAH KULIT
127
L-2-51-0
PROSEDUR PENGANGKATAN PAYUDARA
2.544.294
2.567.192
2.582.458
2.597.724
L-2-52-0
PROSEDUR BESAR PADA PAYUDARA TANPA

PENGANGKATAN PAYUDARA
1.946.468
1.963.987
1.975.665
1.987.344
128
- 31 No
Kode
INA-CBG
129
L-2-53-0
130
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
PROSEDUR KECIL PADA PAYUDARA TANPA

329.929
332.899
334.878
336.858
L-3-10-0
PROSEDUR KECIL LAIN-LAIN PADA PAYUDARA
448.732
452.771
455.463
458.156
131
L-3-11-0
PROSEDUR BESAR PADA KULIT
435.750
439.672
442.286
444.901
132
L-3-12-0
PROSEDUR KECIL PADA KULIT
331.865
334.852
336.843
338.834
133
M-2-10-0
2.602.998
2.626.425
2.642.043
2.657.661
134
M-2-21-0
2.331.164
2.352.145
2.366.132
2.380.119
135
M-2-22-0
567.535
572.643
576.048
579.453
136
M-2-31-0
PROSEDUR BUNION
1.415.948
1.428.692
1.437.187
1.445.683
137
M-2-32-0
PROSEDUR LAIN-LAIN PADA KAKI
448.732
452.771
455.463
458.156
138
M-2-41-0
PROSEDUR EKSISI, INSISI DAN ARTHROTOMI

TULANG
448.732
452.771
455.463
458.156
139
M-2-42-0
PROSEDUR PEMINDAHAN ALAT IMPLAN
154.645
156.037
156.965
157.893
140
M-2-51-0
PROSEDUR BESAR PADA JARINGAN LUNAK
329.929
332.899
334.878
336.858
141
M-2-52-0
PROSEDUR KECIL PADA JARINGAN LUNAK
329.929
332.899
334.878
336.858
142
M-2-61-0
PROSEDUR ARTROSKOPI
1.617.156
1.631.710
1.641.413
1.651.116
143
M-2-62-0
PROSEDUR LAIN-LAIN PADA SENDI & TULANG
329.929
332.899
334.878
336.858
1.625.904
1.640.537
1.650.292
1.660.048
2.217.397
2.237.354
2.250.658
2.263.962
329.929
332.899
334.878
336.858
1.637.022
1.651.755
1.661.577
1.671.399
1.579.796
1.594.014
1.603.493
1.612.972
PROSEDUR REKONTRUKSI TULANG KRANIAL

DAN WAJAH
PROSEDUR BESAR PADA SENDI PANGGUL DAN
PAHA
PROSEDUR KECIL PADA SENDI PANGGUL DAN
PAHA
PROSEDUR INSISI, BIOPSI DAN GRAFT PADA

TULANG
PROSEDUR BESAR PADA TULANG KEPALA &
WAJAH
PROSEDUR KECIL PADA TULANG KEPALA &
WAJAH
PROSEDUR BESAR PADA LUTUT & TUNGKAI
BAWAH
PROSEDUR KECIL PADA LUTUT & TUNGKAI
BAWAH
144
M-2-63-0
145
M-2-64-0
146
M-2-65-0
147
M-2-71-0
148
M-2-72-0
149
M-2-81-0
PROSEDUR BESAR PADA LENGAN, SIKU & BAHU
2.355.812
2.377.014
2.391.149
2.405.284
150
M-2-82-0
PROSEDUR KECIL PADA LENGAN, SIKU & BAHU
1.711.346
1.726.748
1.737.016
1.747.284
151
M-2-83-0
329.929
332.899
334.878
336.858
152
M-2-84-0
329.929
332.899
334.878
336.858
153
M-3-10-0
941.682
950.157
955.807
961.457
154
M-3-11-0
522.105
526.804
529.937
533.069
155
M-3-12-0
1.180.701
1.191.327
1.198.411
1.205.495
156
M-3-13-0
PROSEDUR REDUKSI FRAKTUR TERTUTUP
384.940
388.405
390.714
393.024
157
M-3-14-0
PROSEDUR REDUKSI FRAKTUR WAJAH

TERTUTUP
657.928
663.849
667.797
671.744
158
M-3-15-0
PROSEDUR APLIKASI CASTS DAN SPLINTS
289.858
292.466
294.205
295.945
159
M-3-16-0
PROSEDUR THERAPI FISIK DAN PROSEDUR

KECIL MUSKULOSKLETAL
329.929
332.899
334.878
336.858
160
M-3-17-0
PROSEDUR PEMASANGAN ALAT PROSTETIK
360.200
363.442
365.603
367.764
161
N-2-11-0
PROSEDUR BESAR PADA KANDUNG KEMIH
4.358.688
4.397.917
4.424.069
4.450.221
PROSEDUR BESAR PADA TANGAN &

PERGELANGAN TANGAN
PROSEDUR KECIL PADA TANGAN &
PERGELANGAN TANGAN
PROSEDUR MANIPULATIVE OSTEOPATHIC
PROSEDUR DIAGNOSTIK DAN TERAPEUTIK
MUSKULOSKELETAL
PROSEDUR BIOPSI SENDI DAN TRAKSI
SKELETAL
- 32 No
Kode
INA-CBG
162
N-2-12-0
163
N-2-21-0
164
N-2-22-0
165
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.521.458
2.544.151
2.559.280
2.574.409
2.508.167
2.530.741
2.545.790
2.560.839
PROSEDUR BESAR PADA GINJAL DAN URETER
567.535
572.643
576.048
579.453
N-2-23-0
PROSEDUR SEDANG PADA GINJAL DAN URETER
567.535
572.643
576.048
579.453
166
N-2-24-0
PROSEDUR KECIL PADA GINJAL DAN URETER
1.834.083
1.850.590
1.861.595
1.872.599
167
N-2-31-0
1.544.001
1.557.897
1.567.161
1.576.425
168
N-2-32-0
567.535
572.643
576.048
579.453
169
N-2-41-0
567.535
572.643
576.048
579.453
170
N-2-42-0
959.811
968.449
974.208
979.967
171
N-3-10-0
567.535
572.643
576.048
579.453
172
N-3-11-0
657.571
663.489
667.434
671.380
173
N-3-12-0
508.134
512.707
515.756
518.804
174
N-3-13-0
567.535
572.643
576.048
579.453
175
N-3-14-0
488.333
492.728
495.658
498.588
176
N-3-15-0
1.252.209
1.263.479
1.270.992
1.278.506
177
O-7-10-0
209.065
210.947
212.201
213.455
178
O-7-11-0
1.151.376
1.161.738
1.168.647
1.175.555
179
O-7-12-0
419.255
423.028
425.544
428.059
180
O-7-13-0
233.003
235.100
236.498
237.896
181
P-9-10-0
310.768
313.565
315.430
317.294
182
P-9-11-0
NEONATAL, BBL GROUP-2
310.768
313.565
315.430
317.294
183
P-9-12-0
310.768
313.565
315.430
317.294
184
P-9-13-0
310.768
313.565
315.430
317.294
185
P-9-14-0
310.768
313.565
315.430
317.294
186
P-9-15-0
198.090
199.873
201.062
202.250
187
P-9-16-0
310.768
313.565
315.430
317.294
188
P-9-17-0
309.432
312.216
314.073
315.930
189
Q-5-10-0
PENYALAHGUNAAN ZAT KIMIA AKUT
405.030
408.675
411.105
413.536
190
Q-5-11-0
PENYALAHGUNAAN ZAT KIMIA BUKAN AKUT
303.559
306.291
308.112
309.934
191
Q-5-12-0
GIGI
267.549
269.957
271.562
273.167
192
Q-5-13-0
MEDICAL CHECK-UP
203.325
205.155
206.375
207.595
193
Q-5-14-0
RONGENT (PLAIN FILM)
223.724
225.738
227.080
228.423

MEMINDAHKAN ALAT DIALISIS
EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY
(ESWL) PADA SALURAN KEMIH

DAN URETHRA
PROSEDUR KECIL PADA KANDUNG KEMIH DAN
URETHRA
PROSEDUR BESAR PADA URETHRA DAN
TRANSURETHRA
PROSEDUR KECIL PADA URETHRA DAN
TRANSURETHRA
PROSEDUR PADA GINJAL DAN URETER
PROSEDUR DIAGNOSTIK LAIN PADA STUDI
SALURAN KEMIH
PROSEDUR CYSTOSCOPI & PROSEDUR KECIL
ENDOSKOPI SALURAN KEMIH
PROSEDUR BESAR ENDOSKOPI PADA SALURAN
KEMIH
PROSEDUR KECIL ENDOSKOPI PADA SALURAN
KEMIH
PROSEDUR DIALISIS
PROSEDUR PERSALINAN DENGAN BEDAH
CAESAR
PERSALINAN VAGINAL DENGAN STERILISASI
DAN ATAU PELEBARAN DAN KURETASE
PROSEDUR SELAIN STERILISASI DAN ATAU
PELEBARAN DAN KURETASE
PROSEDUR PERSALINAN MELALUI
VAGINAL/JALAN LAHIR

MAYOR ATAU KONDISI HEREDITER
NEONATAL, BBL GROUP-5 DENGAN SINDROM
ASPIRASI
KONGENITAL/INFEKSI PERINATAL
- 33 No
Kode
INA-CBG
194
Q-5-15-0
195
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
ELEKTROKARDIOGRAM (ECG)
153.855
155.240
156.163
157.086
Q-5-16-0
VAKSINASI
173.892
175.457
176.500
177.544
196
Q-5-17-0
PASANG INFUS
150.412
151.766
152.668
153.571
197
Q-5-18-0
KONSULTASI ATAU PEMERIKSAAN LAIN-LAIN
283.122
285.670
287.369
289.068
198
Q-5-19-0
KONTAK PELAYANAN KESEHATAN LAIN-LAIN
316.514
319.362
321.261
323.161
199
Q-5-20-0
ABORSI MENGANCAM
212.149
214.058
215.331
216.604
200
Q-5-21-0
ABORSI
209.259
211.143
212.398
213.654
201
Q-5-22-0
PERSALINAN YANG SUKAR (FALSE LABOR)
223.724
225.738
227.080
228.423
202
Q-5-23-0
PEMERIKSAAN ANTEPARTUM
273.898
276.363
278.006
279.650
203
Q-5-24-0
PEMERIKSAAN POSTPARTUM
187.068
188.752
189.874
190.997
204
Q-5-25-0
GASTROINTESTINAL AKUT
291.729
294.355
296.105
297.855
205
Q-5-26-0
BRONKIAL AKUT
412.922
416.639
419.116
421.594
206
Q-5-27-0
SISTEM PERSARAFAN PUSAT AKUT
293.856
296.500
298.264
300.027
207
Q-5-28-0
KECEDERAAN SISTEM PERSARAFAN PUSAT
238.456
240.602
242.033
243.464
208
Q-5-29-0
GAGAL JANTUNG KONGESTIF DAN KONDISI

JANTUNG LAIN-LAIN
675.109
681.185
685.236
689.286
209
Q-5-30-0
INFARK MIOKARD AKUT DAN ARITMIA
782.379
789.420
794.114
798.809
210
Q-5-31-0
FRAKTUR
279.121
281.633
283.308
284.983
211
Q-5-32-0
SALURAN KEMIH AKUT
323.286
326.195
328.135
330.075
212
Q-5-33-0
HEMATOLOGI AKUT
338.479
341.525
343.556
345.587
213
Q-5-34-0
INFEKSI VIRUS HIV
480.833
485.160
488.045
490.930
214
Q-5-35-0
INFEKSI AKUT
545.251
550.159
553.430
556.702
215
Q-5-36-0
KEKACAUAN METABOLIK AKUT
634.980
640.695
644.505
648.315
216
Q-5-37-0
CARDIAC ARREST, RESPIRATORY ARREST &

SHOCK
323.872
326.787
328.730
330.674
217
Q-5-38-0
PARU AKUT
431.894
435.781
438.373
440.964
218
Q-5-39-0
KECEDERAAN BESAR PADA JARINGAN LUNAK
276.381
278.868
280.526
282.185
219
Q-5-40-0
INFEKSI SALURAN KEMIH AKUT
271.174
273.614
275.241
276.868
220
Q-5-41-0
PENYAKIT AKUT BESAR LAIN-LAIN
375.402
378.780
381.033
383.285
221
Q-5-42-0
PENYAKIT AKUT KECIL LAIN-LAIN
294.330
296.979
298.745
300.511
222
Q-5-43-0
PENYAKIT KRONIS BESAR LAIN-LAIN
423.852
427.666
430.209
432.753
223
Q-5-44-0
PENYAKIT KRONIS KECIL LAIN-LAIN
345.922
349.035
351.111
353.186
224
T-2-10-0
PEMULIHAN ALKOHOL, OBAT DAN ATAU

TERAPI DETOKSIKASI
179.424
181.039
182.115
183.192
225
U-2-10-0
PROSEDUR BESAR PADA LARING
2.394.613
2.416.164
2.430.532
2.444.900
226
U-2-11-0
PROSEDUR BESAR LAIN-LAIN PADA KEPALA &

LEHER
2.846.264
2.871.880
2.888.958
2.906.036
227
U-2-12-0
PROSEDUR PADA SINUS & MASTOID
313.163
315.982
317.861
319.740
- 34 No
Kode
INA-CBG
228
U-2-13-0
229
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
PROSEDUR KELENJAR LUDAH
410.565
414.260
416.723
419.187
U-2-14-0
PROSEDUR OPERASI BIBIR SUMBING & LANGITLANGIT MULUT
762.643
769.507
774.083
778.659
230
U-2-15-0
PROSEDUR OPERASI TONSIL & AMANDEL
433.317
437.217
439.817
442.417
231
U-2-21-0
504.747
509.290
512.318
515.347
232
U-2-22-0
975.212
983.989
989.840
995.691
233
U-2-23-0
1.277.842
1.289.343
1.297.010
1.304.677
234
U-2-24-0
PROSEDUR KECIL PADA HIDUNG
1.076.943
1.086.636
1.093.098
1.099.559
235
U-2-25-0
PROSEDUR PADA TELINGA TENGAH
410.565
414.260
416.723
419.187
236
U-2-31-0
PROSEDUR BESAR PADA MULUT DAN LIDAH
329.929
332.899
334.878
336.858
237
U-2-32-0
PROSEDUR KECIL PADA MULUT DAN LIDAH
410.565
414.260
416.723
419.187
238
U-3-10-0
392.522
396.054
398.409
400.765
239
U-3-11-0
416.736
420.486
422.987
425.487
240
U-3-12-0
184.280
185.938
187.044
188.150
241
U-3-13-0
405.062
408.707
411.138
413.568
242
U-3-14-0
372.168
375.518
377.751
379.984
243
U-3-15-0
324.564
327.485
329.432
331.380
244
U-3-16-0
PROSEDUR PADA GIGI
366.049
369.343
371.540
373.736
245
V-2-10-0
PROSEDUR BESAR PADA PENGANGKATAN

PROSTAT
3.571.231
3.603.372
3.624.800
3.646.227
246
V-2-11-0
402.744
406.369
408.785
411.202
1.285.213
1.296.780
1.304.492
1.312.203
567.535
572.643
576.048
579.453
567.535
572.643
576.048
579.453
PROSEDUR BESAR PADA TELINGA, HIDUNG,

MULUT DAN TENGGOROKAN
PROSEDUR SEDANG PADA TELINGA, HIDUNG,
PROSEDUR PERBAIKAN HIDUNG
(RHINOPLASTY)
PROSEDUR SEDANG LAIN-LAIN PADA TELINGA,

HIDUNG, MULUT DAN TENGGOROKAN
PROSEDUR KECIL LAIN-LAIN PADA TELINGA,
PROSEDUR KAUTERISASI & PACKING PADA
RONGGA HIDUNG
PROSEDUR DIAGNOSTIK LAIN-LAIN PADA
TELINGA, HIDUNG, MULUT DAN
TENGGOROKAN
PROSEDUR TES FUNGSI PADA TELINGA,
PROSEDUR LAIN-LAIN PADA TELINGA,
PROSEDUR PADA PENIS

PROSEDUR SEDANG PADA PROSTAT DAN
SKROTUM
PROSEDUR KECIL PADA PROSTAT DAN
SKROTUM
PENGANGKATAN PROSTAT MELALUI
TRANSURETHRAL
247
V-2-12-0
248
V-2-13-0
249
V-2-14-0
250
V-2-15-0
SIRKUMSISI/SUNAT
310.768
313.565
315.430
317.294
251
V-3-10-0
PROSEDUR STERILISASI PADA LAKI-LAKI
648.128
653.961
657.850
661.738
252
V-3-11-0
1.371.126
1.383.467
1.391.693
1.399.920
253
V-3-12-0
791.587
798.712
803.461
808.211
254
W-2-10-0
289.858
292.466
294.205
295.945
255
W-2-11-0
740.768
747.435
751.879
756.324
256
W-2-12-0
1.371.126
1.383.467
1.391.693
1.399.920
257
W-2-13-0
219.904
221.883
223.203
224.522
258
W-2-21-0
2.756.329
2.781.136
2.797.674
2.814.212
259
W-2-22-0
289.858
292.466
294.205
295.945

PADA ALAT GENITAL LAKI-LAKI
PROSEDUR LAIN PADA ALAT GENITAL LAKILAKI
PROSEDUR ABORSI
PROSEDUR PELEBARAN, KURETASE DALAM
RAHIM & LEHER RAHIM
PROSEDUR MEMBUKA TUBA YANG
TERHALANG/TERGANGGU
PROSEDUR ENDOSKOPI TUBA YANG
TERHALANG/TERGANGGU
PROSEDUR BESAR PADA FRAKTUR RONGGA
PANGGUL TERBUKA
PROSEDUR KECIL PADA FRAKTUR RONGGA
PANGGUL TERBUKA
- 35 No
Kode
INA-CBG
260
W-2-23-0
Deskripsi (INA-CBG)
PROSEDUR LAPAROSKOPI GINEKOLOGI
PROSEDUR PEMBUANGAN RAHIM MELALUI
JALAN LAHIR
PROSEDUR PERBAIKAN CYSTOCELE DAN
VULVOVAGINAL INTERMEDIATE
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
967.269
975.974
981.778
987.581
3.175.248
3.203.826
3.222.877
3.241.929
2.226.946
2.246.988
2.260.350
2.273.712
261
W-2-31-0
262
W-2-32-0
263
W-2-33-0
PROSEDUR KECIL VULVOVAGINAL
946.481
955.000
960.679
966.358
264
W-2-34-0
PROSEDUR GINEKOLOGI LAIN-LAIN
321.915
324.812
326.744
328.675
265
W-3-10-0
PROSEDUR KECIL GINEKOLOGI & ENDOSKOPI
782.378
789.419
794.114
798.808
266
W-3-11-0
PROSEDUR SEDANG GINEKOLOGI
625.410
631.039
634.792
638.544
267
W-3-12-0
PROSEDUR KECIL GINEKOLOGI
289.858
292.466
294.205
295.945
268
Z-3-10-0
PROSEDUR RADIOSURGICAL
3.281.573
3.311.107
3.330.796
3.350.486
269
Z-3-11-0

(ESWL) SELAIN URINARI DAN SALURAN
EMPEDU
2.508.167
2.530.741
2.545.790
2.560.839
270
Z-3-12-0
PROSEDUR REHABILITASI
418.803
422.573
425.085
427.598
271
Z-3-13-0
PROSEDUR KECIL PELAYANAN PENUNJANG

LAIN-LAIN
2.555.652
2.578.653
2.593.987
2.609.321
272
Z-3-14-0
DIAGNOSTIK TIDUR
505.332
509.880
512.912
515.944
273
Z-3-15-0
IMAGING NUKLIR JANTUNG
329.929
332.899
334.878
336.858
274
Z-3-16-0
PROSEDUR MAGNETIC RESONANCE IMAGING

(MRI)
1.058.972
1.068.503
1.074.857
1.081.211
275
Z-3-17-0
PENGOBATAN NUKLIR
444.580
448.581
451.248
453.916
276
Z-3-18-0
CT-SCAN KEPALA
428.344
432.199
434.769
437.339
277
Z-3-19-0
CT SCAN LAIN-LAIN
445.823
449.835
452.510
455.185
278
Z-3-20-0
IMAGING KONTRAS SALURAN URINARI
303.215
305.944
307.763
309.582
279
Z-3-21-0
IMAGING KONTRAS PEMBULUH DARAH
289.858
292.466
294.205
295.945
280
Z-3-22-0
IMAGING KONTRAS LAIN-LAIN
326.788
329.729
331.690
333.651
281
Z-3-23-0
PROSEDUR ULTRASOUND LAIN-LAIN
340.378
343.442
345.484
347.526
282
Z-3-24-0
PROSEDUR ULTRASOUND PEMBULUH DARAH
668.776
674.795
678.807
682.820
283
Z-3-25-0
PROSEDUR ULTRASOUND GINEKOLOGIK
297.872
300.553
302.340
304.127
284
Z-3-26-0
PROSEDUR BESAR RADIOGRAFI
336.654
339.684
341.704
343.724
285
Z-3-27-0
PERAWATAN LUKA
321.413
324.306
326.234
328.163
286
Z-3-28-0
IMAGING PAYUDARA
329.929
332.899
334.878
336.858
287
Z-3-29-0
IMAGING LAIN-LAIN
950.915
959.474
965.179
970.885
288
Z-3-30-0
FOTOTERAPI
160.479
161.924
162.886
163.849
- 36 B. TARIF INA-CBG RUMAH SAKIT KHUSUS KELAS A

1. RUMAH SAKIT JIWAKELAS A
a. RawatInap
No
Kode
INA-CBG
A-4-10-i
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
SEPTIKEMIA RINGAN
2.465.712
2.539.683
2.588.998
2.638.312
A-4-10-ii
SEPTIKEMIA SEDANG
4.214.122
4.340.546
4.424.829
4.509.111
A-4-10-iii
SEPTIKEMIA BERAT
4.990.823
5.140.548
5.240.364
5.340.181
A-4-11-i
6.616.192
6.814.678
6.947.002
7.079.326
A-4-11-ii
10.221.252
10.527.890
10.732.315
10.936.740
A-4-11-iii
16.719.735
17.221.327
17.555.722
17.890.117
A-4-12-i
DEMAM RINGAN
1.929.531
1.987.417
2.026.008
2.064.598
A-4-12-ii
DEMAM SEDANG
3.722.564
3.834.241
3.908.692
3.983.143
A-4-12-iii
DEMAM BERAT
4.260.201
4.388.007
4.473.211
4.558.415
10
A-4-13-i
2.411.914
2.484.271
2.532.510
2.580.748
11
A-4-13-ii
2.894.297
2.981.126
3.039.012
3.096.897
12
A-4-13-iii
3.517.676
3.623.206
3.693.559
3.763.913
13
A-4-14-i
2.270.139
2.338.243
2.383.646
2.429.049
14
A-4-14-ii
3.702.592
3.813.670
3.887.722
3.961.774
15
A-4-14-iii
4.131.985
4.255.944
4.338.584
4.421.224
16
A-4-15-i
INFEKSI HIV RINGAN
3.034.736
3.125.778
3.186.473
3.247.167
17
A-4-15-ii
INFEKSI HIV SEDANG
4.341.445
4.471.688
4.558.517
4.645.346
18
A-4-15-iii
INFEKSI HIV BERAT
8.121.630
8.365.279
8.527.711
8.690.144
19
B-1-01-i
32.410.848
33.383.173
34.031.390
34.679.607
20
B-1-01-ii
35.757.830
36.830.565
37.545.722
38.260.879
21
B-1-01-iii
62.726.593
64.608.391
65.862.923
67.117.454
22
B-1-10-i
4.201.956
4.328.015
4.412.054
4.496.093
23
B-1-10-ii
10.708.609
11.029.867
11.244.039
11.458.212
24
B-1-10-iii
24.822.063
25.566.725
26.063.166
26.559.608
25
B-1-11-i
3.825.409
3.940.171
4.016.679
4.093.187
26
B-1-11-ii
9.602.136
9.890.201
10.082.243
10.274.286
27
B-1-11-iii
12.038.696
12.399.857
12.640.631
12.881.405
28
B-1-12-i
8.159.734
8.404.526
8.567.721
8.730.916
29
B-1-12-ii
17.488.307
18.012.956
18.362.722
18.712.488

LAIN-LAIN RINGAN
LAIN-LAIN SEDANG
LAIN-LAIN BERAT

(RINGAN)
(SEDANG)
(BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
- 37 No
Kode
INA-CBG
30
B-1-12-iii
31
B-1-13-i
32
B-1-13-ii
33
B-1-13-iii
34
B-1-14-i
35
B-1-14-ii
36
B-1-14-iii
37
B-4-10-i
38
B-4-10-ii
39
B-4-10-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
20.792.261
21.416.029
21.831.874
22.247.719
5.346.892
5.507.299
5.614.237
5.721.175
8.709.312
8.970.591
9.144.777
9.318.963
12.839.969
13.225.168
13.481.968
13.738.767
7.260.704
7.478.525
7.623.739
7.768.953
8.075.368
8.317.629
8.479.136
8.640.643
12.632.953
13.011.941
13.264.600
13.517.259
2.031.434
2.092.377
2.133.006
2.173.635
2.942.823
3.031.107
3.089.964
3.148.820
4.960.105
5.108.908
5.208.111
5.307.313
4.904.644
5.051.783
5.149.876
5.247.969
7.456.284
7.679.972
7.829.098
7.978.223
8.030.676
8.271.597
8.432.210
8.592.824
4.303.489
4.432.594
4.518.663
4.604.733
6.101.289
6.284.327
6.406.353
6.528.379
11.595.357
11.943.217
12.175.125
12.407.032
2.894.297
2.981.126
3.039.012
3.096.897
4.213.587
4.339.995
4.424.267
4.508.538
6.962.980
7.171.869
7.311.129
7.450.388
3.726.807
3.838.611
3.913.147
3.987.684
4.187.904
4.313.541
4.397.299
4.481.057
5.327.413
5.487.235
5.593.783
5.700.332

LAPAROSKOPIK BERAT
LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT

PANCREAS RINGAN
PANCREAS SEDANG
PANCREAS BERAT
(RINGAN)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT
40
B-4-11-i
41
B-4-11-ii
42
B-4-11-iii
43
B-4-12-i
44
B-4-12-ii
45
B-4-12-iii
46
B-4-13-i
47
B-4-13-ii
48
B-4-13-iii
49
B-4-14-i
50
B-4-14-ii
51
B-4-14-iii
52
C-4-10-i
3.791.118
3.904.852
3.980.674
4.056.496
53
C-4-10-ii
7.365.745
7.586.717
7.734.032
7.881.347
54
C-4-10-iii
LEUKEMIA AKUT BERAT
10.870.035
11.196.136
11.413.537
11.630.937
55
C-4-11-i
3.813.852
3.928.268
4.004.545
4.080.822
56
C-4-11-ii
4.369.985
4.501.084
4.588.484
4.675.884
57
C-4-11-iii
8.825.025
9.089.776
9.266.276
9.442.777
58
C-4-12-i
RADIOTERAPI RINGAN
1.929.531
1.987.417
2.026.008
2.064.598
59
C-4-12-ii
RADIOTERAPI SEDANG
7.145.966
7.360.345
7.503.264
7.646.184
60
C-4-12-iii
RADIOTERAPI BERAT
14.507.743
14.942.975
15.233.130
15.523.285
61
C-4-13-i
KEMOTERAPI RINGAN
1.929.531
1.987.417
2.026.008
2.064.598
- 38 No
Kode
INA-CBG
62
C-4-13-ii
63
C-4-13-iii
64
C-4-14-i
65
C-4-14-ii
66
C-4-14-iii
67
D-1-10-i
68
D-1-10-ii
69
D-1-10-iii
70
D-1-11-i
71
72
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
KEMOTERAPI SEDANG
3.859.062
3.974.834
4.052.015
4.129.197
KEMOTERAPI BERAT
5.049.298
5.200.776
5.301.762
5.402.748
3.365.561
3.466.528
3.533.839
3.601.150
4.917.973
5.065.512
5.163.872
5.262.231
7.497.308
7.722.227
7.872.173
8.022.119
20.739.219
21.361.396
21.776.180
22.190.964
31.587.421
32.535.044
33.166.792
33.798.541
42.809.587
44.093.875
44.950.066
45.806.258
5.676.707
5.847.008
5.960.542
6.074.076
D-1-11-ii
12.996.234
13.386.121
13.646.046
13.905.971
D-1-11-iii
20.370.615
20.981.733
21.389.145
21.796.558
5.198.494
5.354.448
5.458.418
5.562.388
14.317.204
14.746.720
15.033.064
15.319.408
22.743.410
23.425.712
23.880.580
24.335.448

RINGAN
SEDANG
BERAT
TULANG RINGAN
TULANG SEDANG
TULANG BERAT

73
D-1-20-i
74
D-1-20-ii
75
D-1-20-iii
76
D-4-10-i
2.236.069
2.303.151
2.347.872
2.392.593
77
D-4-10-ii
3.742.430
3.854.703
3.929.552
4.004.400
78
D-4-10-iii
5.236.369
5.393.460
5.498.187
5.602.915
79
D-4-11-i
2.411.914
2.484.271
2.532.510
2.580.748
80
D-4-11-ii
5.461.946
5.625.804
5.735.043
5.844.282
81
D-4-11-iii
8.274.088
8.522.310
8.687.792
8.853.274
82
D-4-12-i
2.499.073
2.574.045
2.624.027
2.674.008
83
D-4-12-ii
3.466.460
3.570.454
3.639.783
3.709.112
84
D-4-12-iii
5.322.751
5.482.434
5.588.889
5.695.344
1.929.531
1.987.417
2.026.008
2.064.598
2.894.297
2.981.126
3.039.012
3.096.897
3.999.702
4.119.693
4.199.687
4.279.681
2.411.914
2.484.271
2.532.510
2.580.748
5.427.955
5.590.794
5.699.353
5.807.912
6.474.800
6.669.044
6.798.540
6.928.036
6.221.489
6.408.133
6.532.563
6.656.993
8.149.558
8.394.045
8.557.036
8.720.027
16.153.780
16.638.394
16.961.469
17.284.545
4.760.372
4.903.183
4.998.391
5.093.598
85
D-4-13-i
86
D-4-13-ii
87
D-4-13-iii
88
D-4-14-i
89
D-4-14-ii
90
D-4-14-iii
91
E-1-01-i
92
E-1-01-ii
93
E-1-01-iii
94
E-1-10-i

RINGAN
SEDANG
BERAT
- 39 No
Kode
INA-CBG
95
E-1-10-ii
96
E-1-10-iii
97
E-1-20-i
98
E-1-20-ii
99
E-1-20-iii
100
E-4-10-i
101
E-4-10-ii
102
E-4-10-iii
103
E-4-11-i
104
E-4-11-ii
105
E-4-11-iii
106
E-4-12-i
107
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.777.974
5.951.314
6.066.873
6.182.433
12.178.269
12.543.617
12.787.183
13.030.748
7.341.114
7.561.348
7.708.170
7.854.992
9.832.237
10.127.204
10.323.849
10.520.493
21.785.458
22.439.022
22.874.731
23.310.440
3.012.265
3.102.633
3.162.878
3.223.123
4.614.036
4.752.457
4.844.738
4.937.019
7.826.228
8.061.015
8.217.540
8.374.064
2.768.042
2.851.083
2.906.444
2.961.805
5.236.660
5.393.759
5.498.492
5.603.226
8.635.493
8.894.558
9.067.268
9.239.977
2.653.105
2.732.698
2.785.761
2.838.823
E-4-12-ii
4.341.445
4.471.688
4.558.517
4.645.346
108
E-4-12-iii
6.975.048
7.184.299
7.323.800
7.463.301
109
E-4-13-i
3.488.684
3.593.344
3.663.118
3.732.892
110
E-4-13-ii
5.990.095
6.169.798
6.289.599
6.409.401
111
E-4-13-iii
10.364.377
10.675.308
10.882.596
11.089.883
112
F-4-10-i
SCHIZOFRENIA RINGAN
5.555.114
5.721.768
5.832.870
5.943.972
113
F-4-10-ii
SCHIZOFRENIA SEDANG
6.169.133
6.354.207
6.477.590
6.600.972
114
F-4-10-iii
SCHIZOFRENIA BERAT
9.133.537
9.407.543
9.590.214
9.772.885
115
F-4-11-i
5.120.470
5.274.084
5.376.493
5.478.903
116
F-4-11-ii
5.965.833
6.144.808
6.264.125
6.383.442
117
F-4-11-iii
DEPRESI MAYOR BERAT
7.650.379
7.879.890
8.032.898
8.185.905
118
F-4-12-i
2.810.382
2.894.693
2.950.901
3.007.109
119
F-4-12-ii
4.012.827
4.133.212
4.213.468
4.293.725
120
F-4-12-iii
8.705.155
8.966.309
9.140.412
9.314.515
121
F-4-13-i
4.138.117
4.262.261
4.345.023
4.427.786
122
F-4-13-ii
5.479.931
5.644.329
5.753.928
5.863.526
123
F-4-13-iii
7.065.671
7.277.641
7.418.955
7.560.268
124
F-4-14-i
DEPRESI RINGAN
2.896.683
2.983.583
3.041.517
3.099.450
125
F-4-14-ii
DEPRESI SEDANG
3.715.582
3.827.050
3.901.362
3.975.673
126
F-4-14-iii
DEPRESI BERAT
4.999.482
5.149.466
5.249.456
5.349.446
127
F-4-15-i
3.747.176
3.859.591
3.934.535
4.009.478

RINGAN
SEDANG
BERAT

RINGAN
SEDANG
BERAT

IMPULSE RINGAN
IMPULSE SEDANG
IMPULSE BERAT
- 40 No
Kode
INA-CBG
128
F-4-15-ii
129
F-4-15-iii
130
F-4-16-i
131
F-4-16-ii
132
F-4-16-iii
133
F-4-17-i
134
F-4-17-ii
135
F-4-17-iii
136
F-4-18-i
137
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.620.764
5.789.387
5.901.802
6.014.217
7.402.891
7.624.978
7.773.035
7.921.093
7.417.681
7.640.212
7.788.566
7.936.919
8.622.869
8.881.555
9.054.012
9.226.470
11.510.091
11.855.393
12.085.595
12.315.797
1.898.679
1.955.639
1.993.613
2.031.586
5.564.847
5.731.792
5.843.089
5.954.386
5.937.282
6.115.401
6.234.146
6.352.892
6.429.396
6.622.278
6.750.866
6.879.454
F-4-18-ii
7.074.152
7.286.376
7.427.859
7.569.342
138
F-4-18-iii
10.905.422
11.232.584
11.450.693
11.668.801
139
F-4-19-i
4.930.740
5.078.662
5.177.277
5.275.892
140
F-4-19-ii
6.313.940
6.503.358
6.629.637
6.755.916
141
F-4-19-iii
7.860.939
8.096.768
8.253.986
8.411.205
9.038.820
9.309.985
9.490.761
9.671.538
15.299.292
15.758.271
16.064.257
16.370.243
29.617.721
30.506.253
31.098.607
31.690.962

RINGAN
SEDANG
BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT
142
G-1-01-i
143
G-1-01-ii
144
G-1-01-iii
145
G-1-10-i
6.007.046
6.187.257
6.307.398
6.427.539
146
G-1-10-ii
8.480.455
8.734.869
8.904.478
9.074.087
147
G-1-10-iii
10.051.151
10.352.685
10.553.708
10.754.731
148
G-1-11-i
6.929.307
7.137.186
7.275.772
7.414.358
149
G-1-11-ii
14.229.853
14.656.749
14.941.346
15.225.943
150
G-1-11-iii
25.992.468
26.772.242
27.292.092
27.811.941
5.388.959
5.550.628
5.658.407
5.766.186
11.696.611
12.047.509
12.281.441
12.515.373
17.294.135
17.812.959
18.158.842
18.504.725

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT
151
G-1-12-i
152
G-1-12-ii
153
G-1-12-iii
154
G-1-13-i
1.067.239
1.099.256
1.120.601
1.141.946
155
G-1-13-ii
2.866.486
2.952.481
3.009.810
3.067.140
156
G-1-13-iii
6.468.000
6.662.040
6.791.400
6.920.760
6.790.547
6.994.263
7.130.074
7.265.885
9.174.251
9.449.479
9.632.964
9.816.449
22.462.075
23.135.937
23.585.179
24.034.420
8.660.731
8.920.553
9.093.768
9.266.982
157
G-1-20-i
158
G-1-20-ii
159
G-1-20-iii
160
G-1-30-i

RINGAN
SEDANG
BERAT
- 41 No
Kode
INA-CBG
161
G-1-30-ii
162
G-1-30-iii
163
G-4-10-i
164
G-4-10-ii
165
G-4-10-iii
166
G-4-11-i
167
G-4-11-ii
168
G-4-11-iii
169
G-4-12-i
170
G-4-12-ii
171
G-4-12-iii
172
G-4-13-i
173
G-4-13-ii
174
G-4-13-iii
175
G-4-14-i
176
G-4-14-ii
177
G-4-14-iii
178
G-4-15-i
179
G-4-15-ii
180
G-4-15-iii
181
G-4-16-i
182
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
22.605.339
23.283.499
23.735.605
24.187.712
29.100.056
29.973.058
30.555.059
31.137.060
2.894.297
2.981.126
3.039.012
3.096.897
3.958.119
4.076.862
4.156.025
4.235.187
6.938.885
7.147.052
7.285.829
7.424.607
6.423.378
6.616.079
6.744.547
6.873.014
7.451.118
7.674.652
7.823.674
7.972.696
10.919.742
11.247.334
11.465.729
11.684.124
4.804.121
4.948.245
5.044.327
5.140.410
6.053.193
6.234.788
6.355.852
6.476.916
8.791.542
9.055.288
9.231.119
9.406.950
2.672.981
2.753.170
2.806.630
2.860.089
3.713.942
3.825.360
3.899.639
3.973.918
4.335.169
4.465.224
4.551.927
4.638.631
4.888.483
5.035.138
5.132.908
5.230.677
8.043.205
8.284.501
8.445.365
8.606.229
10.070.276
10.372.384
10.573.790
10.775.195
3.237.168
3.334.283
3.399.026
3.463.770
4.019.991
4.140.590
4.220.990
4.301.390
5.924.017
6.101.738
6.220.218
6.338.698
2.701.475
2.782.519
2.836.549
2.890.578
G-4-16-ii
3.908.633
4.025.892
4.104.064
4.182.237
183
G-4-16-iii
6.877.316
7.083.635
7.221.181
7.358.728
184
G-4-17-i
4.636.360
4.775.451
4.868.178
4.960.905
185
G-4-17-ii
5.753.927
5.926.545
6.041.623
6.156.702
186
G-4-17-iii
9.643.629
9.932.937
10.125.810
10.318.683
187
G-4-18-i
2.918.752
3.006.315
3.064.690
3.123.065
188
G-4-18-ii
5.582.068
5.749.530
5.861.171
5.972.812
189
G-4-18-iii
5.913.632
6.091.041
6.209.314
6.327.587
190
G-4-19-i
3.242.538
3.339.815
3.404.665
3.469.516

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
DEGENERATIF RINGAN
DEGENERATIF SEDANG
DEGENERATIF BERAT
RINGAN
SEDANG
BERAT
TRAUMATIK RINGAN
TRAUMATIK SEDANG
TRAUMATIK BERAT
DENGAN INFARK BERAT
TANPA INFARK RINGAN
TANPA INFARK SEDANG
TANPA INFARK BERAT

PERIFER RINGAN
PERIFER SEDANG
PERIFER BERAT
PERSARAFAN RINGAN
PERSARAFAN SEDANG
PERSARAFAN BERAT
- 42 No
Kode
INA-CBG
191
G-4-19-ii
192
G-4-19-iii
193
G-4-20-i
194
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.743.622
5.915.931
6.030.803
6.145.676
8.171.197
8.416.333
8.579.757
8.743.181
1.904.186
1.961.312
1.999.395
2.037.479
G-4-20-ii
2.620.430
2.699.043
2.751.451
2.803.860
195
G-4-20-iii
4.328.212
4.458.058
4.544.623
4.631.187
196
G-4-21-i
2.631.558
2.710.505
2.763.136
2.815.767
197
G-4-21-ii
3.657.865
3.767.601
3.840.759
3.913.916
198
G-4-21-iii
6.421.001
6.613.631
6.742.051
6.870.471
199
G-4-22-i
1.929.531
1.987.417
2.026.008
2.064.598
200
G-4-22-ii
2.411.914
2.484.271
2.532.510
2.580.748
201
G-4-22-iii
2.767.096
2.850.109
2.905.451
2.960.793
202
G-4-23-i
2.373.309
2.444.508
2.491.974
2.539.440
203
G-4-23-ii
2.468.822
2.542.887
2.592.263
2.641.640
204
G-4-23-iii
3.514.996
3.620.446
3.690.746
3.761.046
205
G-4-24-i
1.986.986
2.046.595
2.086.335
2.126.075
206
G-4-24-ii
2.880.353
2.966.764
3.024.371
3.081.978
207
G-4-24-iii
TRAUMA KEPALA BERAT
5.563.560
5.730.467
5.841.738
5.953.009
208
G-4-25-i
GEGAR OTAK RINGAN
1.929.531
1.987.417
2.026.008
2.064.598
209
G-4-25-ii
GEGAR OTAK SEDANG
2.411.914
2.484.271
2.532.510
2.580.748
210
G-4-25-iii
GEGAR OTAK BERAT
3.011.733
3.102.085
3.162.319
3.222.554
211
G-4-26-i
3.911.296
4.028.635
4.106.861
4.185.087
212
G-4-26-ii
4.435.540
4.568.606
4.657.317
4.746.028
213
G-4-26-iii
6.510.502
6.705.818
6.836.028
6.966.238
214
H-1-20-i
3.730.630
3.842.549
3.917.162
3.991.775
215
H-1-20-ii
6.803.227
7.007.324
7.143.388
7.279.453
216
H-1-20-iii
9.251.964
9.529.523
9.714.562
9.899.601
217
H-1-30-i
3.652.643
3.762.222
3.835.275
3.908.328
218
H-1-30-ii
4.164.012
4.288.933
4.372.213
4.455.493
219
H-1-30-iii
6.947.504
7.155.929
7.294.879
7.433.830
220
H-4-10-i
3.308.682
3.407.943
3.474.117
3.540.290
221
H-4-10-ii
5.386.610
5.548.208
5.655.940
5.763.673
222
H-4-10-iii
8.457.657
8.711.387
8.880.540
9.049.693
223
H-4-11-i
2.650.791
2.730.314
2.783.330
2.836.346

SEDANG

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)

RINGAN
SEDANG
- 43 No
Kode
INA-CBG
224
H-4-11-ii
225
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.925.964
3.013.743
3.072.262
3.130.781
H-4-11-iii
3.882.132
3.998.596
4.076.239
4.153.881
226
H-4-12-i
3.677.866
3.788.202
3.861.759
3.935.317
227
H-4-12-ii
4.981.910
5.131.367
5.231.005
5.330.644
228
H-4-12-iii
8.311.977
8.561.336
8.727.576
8.893.815
229
I-1-01-i
42.046.422
43.307.815
44.148.744
44.989.672
230
I-1-01-ii
42.971.663
44.260.813
45.120.246
45.979.679
231
I-1-01-iii
67.829.946
69.864.844
71.221.443
72.578.042
232
I-1-02-i
23.327.113
24.026.926
24.493.469
24.960.011
233
I-1-02-ii
30.091.976
30.994.735
31.596.575
32.198.414
234
I-1-02-iii
37.090.110
38.202.813
38.944.615
39.686.417
235
I-1-03-i
14.222.476
14.649.150
14.933.599
15.218.049
236
I-1-03-ii
19.494.351
20.079.182
20.469.069
20.858.956
237
I-1-03-iii
28.591.715
29.449.467
30.021.301
30.593.135
238
I-1-04-i
23.338.875
24.039.041
24.505.819
24.972.596
239
I-1-04-ii
29.979.199
30.878.575
31.478.159
32.077.743
240
I-1-04-iii
63.909.429
65.826.712
67.104.900
68.383.089
241
I-1-05-i
30.874.120
31.800.344
32.417.826
33.035.309
242
I-1-05-ii
37.048.944
38.160.412
38.901.391
39.642.370
243
I-1-05-iii
50.979.113
52.508.487
53.528.069
54.547.651
244
I-1-06-i
19.380.657
19.962.076
20.349.689
20.737.303
245
I-1-06-ii
25.360.931
26.121.759
26.628.977
27.136.196
246
I-1-06-iii
27.994.318
28.834.147
29.394.034
29.953.920
247
I-1-07-i
25.487.031
26.251.642
26.761.382
27.271.123
248
I-1-07-ii
31.443.430
32.386.733
33.015.602
33.644.470
249
I-1-07-iii
34.304.578
35.333.715
36.019.807
36.705.898
250
I-1-11-i
4.848.255
4.993.702
5.090.668
5.187.633
251
I-1-11-ii
5.390.774
5.552.498
5.660.313
5.768.129
252
I-1-11-iii
7.173.478
7.388.682
7.532.152
7.675.621

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
KATETERISASI RINGAN
KATETERISASI SEDANG
KATETERISASI BERAT
RINGAN
SEDANG
BERAT

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
RINGAN
SEDANG
BERAT
- 44 No
Kode
INA-CBG
253
I-1-12-i
254
I-1-12-ii
255
I-1-12-iii
256
I-1-13-i
257
I-1-13-ii
258
I-1-13-iii
259
I-1-14-i
260
I-1-14-ii
261
I-1-14-iii
262
I-1-15-i
263
264
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
12.392.862
12.764.648
13.012.505
13.260.362
16.717.114
17.218.628
17.552.970
17.887.312
22.828.956
23.513.825
23.970.404
24.426.983
7.570.372
7.797.483
7.948.891
8.100.298
8.512.220
8.767.587
8.937.831
9.108.076
18.537.753
19.093.886
19.464.641
19.835.396
24.013.205
24.733.601
25.213.865
25.694.129
29.844.983
30.740.332
31.337.232
31.934.132
39.107.219
40.280.435
41.062.580
41.844.724
7.641.715
7.870.966
8.023.800
8.176.635
I-1-15-ii
14.000.147
14.420.151
14.700.154
14.980.157
I-1-15-iii
24.158.025
24.882.766
25.365.926
25.849.087
10.291.373
10.600.115
10.805.942
11.011.770
26.757.571
27.560.298
28.095.449
28.630.601
30.864.201
31.790.127
32.407.411
33.024.695
4.395.294
4.527.153
4.615.059
4.702.965
9.104.247
9.377.375
9.559.460
9.741.545
52.780.889
54.364.315
55.419.933
56.475.551
6.944.436
7.152.769
7.291.658
7.430.546
11.696.611
12.047.509
12.281.441
12.515.373
22.545.537
23.221.903
23.672.814
24.123.725
11.675.617
12.025.885
12.259.397
12.492.910
24.287.641
25.016.270
25.502.023
25.987.776
37.637.023
38.766.133
39.518.874
40.271.614
20.909.039
21.536.310
21.954.490
22.372.671
26.952.538
27.761.114
28.300.165
28.839.216
32.415.309
33.387.768
34.036.075
34.684.381

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

DARAH VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
265
I-1-16-i
266
I-1-16-ii
267
I-1-16-iii
268
I-1-17-i
269
I-1-17-ii
270
I-1-17-iii
271
I-1-20-i
272
I-1-20-ii
273
I-1-20-iii
274
I-1-30-i
275
I-1-30-ii
276
I-1-30-iii
277
I-1-40-i
278
I-1-40-ii
279
I-1-40-iii
280
I-4-10-i
6.080.956
6.263.385
6.385.004
6.506.623
281
I-4-10-ii
9.601.939
9.889.997
10.082.035
10.274.074
- 45 No
Kode
INA-CBG
282
I-4-10-iii
283
I-4-11-i
284
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
13.851.634
14.267.183
14.544.216
14.821.248
6.218.481
6.405.036
6.529.406
6.653.775
I-4-11-ii
7.235.742
7.452.814
7.597.529
7.742.244
285
I-4-11-iii
11.739.972
12.092.171
12.326.970
12.561.770
286
I-4-12-i
6.315.582
6.505.049
6.631.361
6.757.672
287
I-4-12-ii
9.012.317
9.282.686
9.462.933
9.643.179
288
I-4-12-iii
10.933.208
11.261.205
11.479.869
11.698.533
289
I-4-13-i
5.673.128
5.843.322
5.956.785
6.070.247
290
I-4-13-ii
8.241.898
8.489.155
8.653.993
8.818.831
291
I-4-13-iii
13.564.047
13.970.968
14.242.249
14.513.530
292
I-4-14-i
3.528.162
3.634.007
3.704.570
3.775.133
293
I-4-14-ii
4.128.471
4.252.325
4.334.895
4.417.464
294
I-4-14-iii
6.397.757
6.589.689
6.717.645
6.845.600
3.859.062
3.974.834
4.052.015
4.129.197
7.430.935
7.653.863
7.802.482
7.951.101
8.469.478
8.723.563
8.892.952
9.062.342

VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT

295
I-4-15-i
296
I-4-15-ii
297
I-4-15-iii
298
I-4-16-i
3.004.725
3.094.867
3.154.961
3.215.056
299
I-4-16-ii
4.819.172
4.963.747
5.060.131
5.156.514
300
I-4-16-iii
6.050.180
6.231.685
6.352.689
6.473.693
301
I-4-17-i
HIPERTENSI RINGAN
3.484.266
3.588.794
3.658.480
3.728.165
302
I-4-17-ii
HIPERTENSI SEDANG
4.753.174
4.895.769
4.990.832
5.085.896
303
I-4-17-iii
HIPERTENSI BERAT
5.555.506
5.722.171
5.833.281
5.944.391
5.131.324
5.285.263
5.387.890
5.490.516
7.860.844
8.096.670
8.253.887
8.411.103
10.597.678
10.915.608
11.127.562
11.339.515
4.015.933
4.136.411
4.216.730
4.297.049
6.519.286
6.714.864
6.845.250
6.975.636
7.467.634
7.691.663
7.841.016
7.990.369

RINGAN
SEDANG
KONGENITAL BERAT
RINGAN
SEDANG
BERAT
304
I-4-18-i
305
I-4-18-ii
306
I-4-18-iii
307
I-4-19-i
308
I-4-19-ii
309
I-4-19-iii
310
I-4-20-i
4.873.904
5.020.121
5.117.599
5.215.077
311
I-4-20-ii
5.615.101
5.783.554
5.895.857
6.008.159
312
I-4-20-iii
7.452.174
7.675.739
7.824.783
7.973.826
313
I-4-21-i
6.481.503
6.675.948
6.805.578
6.935.208
314
I-4-21-ii
8.085.255
8.327.813
8.489.518
8.651.223
- 46 No
Kode
INA-CBG
315
I-4-21-iii
316
I-4-22-i
317
318
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
11.030.002
11.360.902
11.581.502
11.802.102
3.135.488
3.229.553
3.292.263
3.354.972
I-4-22-ii
3.613.021
3.721.411
3.793.672
3.865.932
I-4-22-iii
5.271.299
5.429.438
5.534.864
5.640.290
2.399.224
2.471.200
2.519.185
2.567.169
2.945.694
3.034.064
3.092.978
3.151.892
5.755.617
5.928.285
6.043.397
6.158.510
3.810.753
3.925.075
4.001.290
4.077.505
9.514.395
9.799.827
9.990.115
10.180.403
12.029.234
12.390.111
12.630.696
12.871.280
30.702.063
31.623.125
32.237.166
32.851.208
32.798.903
33.782.870
34.438.848
35.094.826
56.037.118
57.718.232
58.838.974
59.959.716
15.694.286
16.165.114
16.479.000
16.792.886
16.812.762
17.317.145
17.653.400
17.989.655
24.844.471
25.589.805
26.086.695
26.583.584
6.124.137
6.307.861
6.430.344
6.552.827
14.792.017
15.235.778
15.531.618
15.827.458
22.366.749
23.037.751
23.485.086
23.932.421
5.198.494
5.354.448
5.458.418
5.562.388
7.698.562
7.929.519
8.083.490
8.237.461
10.101.168
10.404.203
10.606.227
10.808.250
3.569.507
3.676.592
3.747.982
3.819.372
15.318.139
15.777.683
16.084.046
16.390.409
41.781.754
43.035.206
43.870.841
44.706.476

RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
319
I-4-23-i
320
I-4-23-ii
321
I-4-23-iii
322
I-4-24-i
323
I-4-24-ii
324
I-4-24-iii
325
J-1-01-i
326
J-1-01-ii
327
J-1-01-iii
328
J-1-02-i
329
J-1-02-ii
330
J-1-02-iii
331
J-1-10-i
332
J-1-10-ii
333
J-1-10-iii
334
J-1-20-i
335
J-1-20-ii
336
J-1-20-iii
337
J-1-30-i
338
J-1-30-ii
339
J-1-30-iii
340
J-4-10-i
3.093.567
3.186.374
3.248.245
3.310.116
341
J-4-10-ii
4.423.429
4.556.132
4.644.600
4.733.069
342
J-4-10-iii
6.691.987
6.892.747
7.026.587
7.160.426
343
J-4-11-i
2.598.999
2.676.968
2.728.948
2.780.928
344
J-4-11-ii
3.617.747
3.726.279
3.798.634
3.870.989
345
J-4-11-iii
5.184.323
5.339.853
5.443.539
5.547.226
- 47 No
Kode
INA-CBG
346
J-4-12-i
347
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
EMBOLI PARU RINGAN
2.984.575
3.074.112
3.133.804
3.193.495
J-4-12-ii
EMBOLI PARU SEDANG
3.864.923
3.980.870
4.058.169
4.135.467
348
J-4-12-iii
EMBOLI PARU BERAT
5.161.214
5.316.050
5.419.274
5.522.499
349
J-4-13-i
6.122.307
6.305.976
6.428.422
6.550.868
350
J-4-13-ii
8.999.791
9.269.784
9.449.780
9.629.776
351
J-4-13-iii
14.632.313
15.071.282
15.363.928
15.656.574
352
J-4-14-i
TUMOR PARU RINGAN
4.172.158
4.297.323
4.380.766
4.464.210
353
J-4-14-ii
TUMOR PARU SEDANG
6.988.936
7.198.604
7.338.383
7.478.162
354
J-4-14-iii
TUMOR PARU BERAT
8.309.490
8.558.775
8.724.965
8.891.154
3.652.566
3.762.143
3.835.194
3.908.246
5.143.030
5.297.321
5.400.181
5.503.042
6.462.875
6.656.762
6.786.019
6.915.277
2.494.943
2.569.791
2.619.690
2.669.589
4.293.914
4.422.732
4.508.610
4.594.488
7.035.738
7.246.811
7.387.525
7.528.240

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
355
J-4-15-i
356
J-4-15-ii
357
J-4-15-iii
358
J-4-16-i
359
J-4-16-ii
360
J-4-16-iii
361
J-4-17-i
2.990.333
3.080.043
3.139.849
3.199.656
362
J-4-17-ii
4.058.750
4.180.512
4.261.687
4.342.862
363
J-4-17-iii
6.509.883
6.705.179
6.835.377
6.965.574
364
J-4-18-i
2.026.659
2.087.459
2.127.992
2.168.525
365
J-4-18-ii
3.100.788
3.193.812
3.255.828
3.317.843
366
J-4-18-iii
3.242.654
3.339.934
3.404.787
3.469.640
367
J-4-19-i
3.789.494
3.903.178
3.978.968
4.054.758
368
J-4-19-ii
5.142.992
5.297.282
5.400.142
5.503.001
369
J-4-19-iii
7.351.618
7.572.166
7.719.199
7.866.231
370
J-4-20-i
4.183.125
4.308.619
4.392.282
4.475.944
371
J-4-20-ii
5.540.375
5.706.587
5.817.394
5.928.202
372
J-4-20-iii
11.043.451
11.374.754
11.595.623
11.816.492
2.328.423
2.398.276
2.444.844
2.491.413
5.187.899
5.343.536
5.447.294
5.551.052
7.237.865
7.455.001
7.599.758
7.744.516
5.198.494
5.354.448
5.458.418
5.562.388
9.758.501
10.051.256
10.246.426
10.441.596
11.428.885
11.771.752
12.000.329
12.228.907
373
J-4-21-i
374
J-4-21-ii
375
J-4-21-iii
376
K-1-10-i
377
K-1-10-ii
378
K-1-10-iii

USUS BESAR (RINGAN)
USUS BESAR (SEDANG)
USUS BESAR (BERAT)
- 48 No
Kode
INA-CBG
Deskripsi (INA-CBG)
379
K-1-11-i
380
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
6.012.480
6.192.854
6.313.104
6.433.353
K-1-11-ii
7.893.660
8.130.470
8.288.343
8.446.216
381
K-1-11-iii
20.032.556
20.633.532
21.034.183
21.434.834
382
K-1-12-i
3.234.254
3.331.281
3.395.966
3.460.652
383
K-1-12-ii
4.215.233
4.341.690
4.425.995
4.510.300
384
K-1-12-iii
8.384.985
8.636.535
8.804.234
8.971.934
385
K-1-13-i
3.673.669
3.783.879
3.857.353
3.930.826
386
K-1-13-ii
6.416.845
6.609.350
6.737.687
6.866.024
387
K-1-13-iii
6.862.584
7.068.461
7.205.713
7.342.965
388
K-1-14-i
5.936.867
6.114.973
6.233.710
6.352.447
389
K-1-14-ii
6.973.522
7.182.728
7.322.198
7.461.669
390
K-1-14-iii
16.454.389
16.948.021
17.277.109
17.606.196
391
K-1-20-i
11.519.263
11.864.841
12.095.226
12.325.611
392
K-1-20-ii
16.077.853
16.560.189
16.881.746
17.203.303
393
K-1-20-iii
32.943.483
33.931.787
34.590.657
35.249.526
394
K-1-30-i
7.582.552
7.810.029
7.961.680
8.113.331
395
K-1-30-ii
10.396.987
10.708.897
10.916.837
11.124.776
396
K-1-30-iii
21.779.862
22.433.257
22.868.855
23.304.452
397
K-1-40-i
7.617.589
7.846.117
7.998.468
8.150.820
398
K-1-40-ii
8.382.400
8.633.872
8.801.520
8.969.168
399
K-1-40-iii
13.901.403
14.318.445
14.596.473
14.874.501
400
K-1-50-i
5.810.382
5.984.694
6.100.902
6.217.109
401
K-1-50-ii
7.524.719
7.750.461
7.900.955
8.051.450
402
K-1-50-iii
PROSEDUR ANAL BERAT
10.683.100
11.003.593
11.217.255
11.430.917
403
K-4-10-i
4.400.947
4.532.975
4.620.994
4.709.013
404
K-4-10-ii
5.265.991
5.423.971
5.529.291
5.634.611
405
K-4-10-iii
17.742.998
18.275.288
18.630.148
18.985.008
406
K-4-11-i
2.174.146
2.239.370
2.282.853
2.326.336
407
K-4-11-ii
3.528.519
3.634.375
3.704.945
3.775.515
408
K-4-11-iii
5.918.020
6.095.560
6.213.921
6.332.281
409
K-4-12-i
2.219.812
2.286.406
2.330.802
2.375.199
410
K-4-12-ii
3.877.512
3.993.838
4.071.388
4.148.938
411
K-4-12-iii
8.530.692
8.786.612
8.957.226
9.127.840


RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
- 49 No
Kode
INA-CBG
412
K-4-13-i
413
K-4-13-ii
414
K-4-13-iii
415
K-4-14-i
416
K-4-14-ii
417
K-4-14-iii
418
K-4-15-i
419
K-4-15-ii
420
K-4-15-iii
421
K-4-16-i
422
K-4-16-ii
423
K-4-16-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.053.355
3.144.955
3.206.022
3.267.090
3.916.488
4.033.983
4.112.313
4.190.642
6.323.089
6.512.782
6.639.244
6.765.706
2.514.871
2.590.317
2.640.614
2.690.912
3.375.812
3.477.086
3.544.603
3.612.119
5.926.851
6.104.657
6.223.194
6.341.731
2.656.097
2.735.780
2.788.902
2.842.024
4.800.615
4.944.633
5.040.645
5.136.658
6.737.432
6.939.555
7.074.304
7.209.053
2.670.307
2.750.416
2.803.822
2.857.228
3.536.086
3.642.169
3.712.890
3.783.612
4.752.065
4.894.627
4.989.668
5.084.710
1.929.531
1.987.417
2.026.008
2.064.598
3.786.762
3.900.364
3.976.100
4.051.835
4.603.387
4.741.489
4.833.557
4.925.625
2.586.963
2.664.572
2.716.312
2.768.051
4.029.164
4.150.039
4.230.622
4.311.205
4.684.986
4.825.535
4.919.235
5.012.935
26.559.553
27.356.339
27.887.530
28.418.721
27.354.811
28.175.455
28.722.552
29.269.648
38.338.891
39.489.057
40.255.835
41.022.613
9.097.364
9.370.285
9.552.232
9.734.179
17.449.584
17.973.072
18.322.063
18.671.055
18.403.867
18.955.983
19.324.060
19.692.137
4.864.079
5.010.001
5.107.283
5.204.565
10.396.987
10.708.897
10.916.837
11.124.776
14.914.907
15.362.355
15.660.653
15.958.951

(RINGAN)
(SEDANG)
RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
424
K-4-17-i
425
K-4-17-ii
426
K-4-17-iii
427
K-4-18-i
428
K-4-18-ii
429
K-4-18-iii
430
L-1-20-i
431
L-1-20-ii
432
L-1-20-iii
433
L-1-30-i
434
L-1-30-ii
435
L-1-30-iii
436
L-1-40-i
437
L-1-40-ii
438
L-1-40-iii
439
L-1-50-i
6.498.117
6.693.061
6.823.023
6.952.985
440
L-1-50-ii
11.696.611
12.047.509
12.281.441
12.515.373
441
L-1-50-iii
14.142.857
14.567.143
14.850.000
15.132.857
442
L-4-10-i
3.207.084
3.303.297
3.367.438
3.431.580
- 50 No
Kode
INA-CBG
443
L-4-10-ii
444
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.464.308
4.598.238
4.687.524
4.776.810
L-4-10-iii
9.188.036
9.463.677
9.647.438
9.831.199
445
L-4-11-i
3.682.187
3.792.653
3.866.297
3.939.941
446
L-4-11-ii
5.044.532
5.195.868
5.296.759
5.397.650
447
L-4-11-iii
13.680.141
14.090.545
14.364.148
14.637.751
448
L-4-12-i
3.634.968
3.744.017
3.816.716
3.889.415
449
L-4-12-ii
5.712.118
5.883.481
5.997.724
6.111.966
450
L-4-12-iii
9.250.571
9.528.088
9.713.099
9.898.110
451
L-4-13-i
2.443.597
2.516.905
2.565.777
2.614.649
452
L-4-13-ii
2.817.612
2.902.140
2.958.492
3.014.844
453
L-4-13-iii
4.226.637
4.353.436
4.437.969
4.522.502
454
L-4-14-i
2.226.856
2.293.662
2.338.199
2.382.736
455
L-4-14-ii
3.309.683
3.408.973
3.475.167
3.541.360
456
L-4-14-iii
6.086.971
6.269.580
6.391.320
6.513.059
457
M-1-01-i
9.501.927
9.786.985
9.977.023
10.167.062
458
M-1-01-ii
10.605.688
10.923.858
11.135.972
11.348.086
459
M-1-01-iii
14.898.118
15.345.061
15.643.024
15.940.986
460
M-1-02-i
8.962.024
9.230.885
9.410.126
9.589.366
461
M-1-02-ii
14.713.940
15.155.358
15.449.637
15.743.916
462
M-1-02-iii
25.282.765
26.041.248
26.546.903
27.052.558
16.895.104
17.401.957
17.739.860
18.077.762
19.772.213
20.365.379
20.760.824
21.156.268
25.731.382
26.503.324
27.017.951
27.532.579
5.911.979
6.089.338
6.207.578
6.325.817
7.579.096
7.806.468
7.958.050
8.109.632
9.483.809
9.768.324
9.958.000
10.147.676
9.209.728
9.486.020
9.670.214
9.854.409
10.643.977
10.963.297
11.176.176
11.389.056
18.129.592
18.673.480
19.036.072
19.398.664
7.634.068
7.863.090
8.015.772
8.168.453
10.227.266
10.534.084
10.738.629
10.943.175
20.833.911
21.458.928
21.875.606
22.292.284
463
M-1-03-i
464
M-1-03-ii
465
M-1-03-iii
466
M-1-04-i
467
M-1-04-ii
468
M-1-04-iii
469
M-1-05-i
470
M-1-05-ii
471
M-1-05-iii
472
M-1-07-i
473
M-1-07-ii
474
M-1-07-iii


- 51 No
Kode
INA-CBG
475
M-1-10-i
476
M-1-10-ii
477
M-1-10-iii
478
M-1-20-i
479
M-1-20-ii
480
M-1-20-iii
481
M-1-30-i
482
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
6.353.711
6.544.322
6.671.397
6.798.471
23.601.157
24.309.192
24.781.215
25.253.238
27.517.258
28.342.776
28.893.121
29.443.466
6.285.462
6.474.026
6.599.735
6.725.444
8.971.933
9.241.091
9.420.529
9.599.968
17.439.481
17.962.666
18.311.455
18.660.245
3.759.646
3.872.435
3.947.628
4.022.821
M-1-30-ii
7.768.384
8.001.436
8.156.804
8.312.171
483
M-1-30-iii
PROSEDUR KAKI BERAT
11.588.792
11.936.455
12.168.231
12.400.007
484
M-1-40-i
3.712.652
3.824.031
3.898.284
3.972.537
485
M-1-40-ii
6.110.856
6.294.181
6.416.398
6.538.615
486
M-1-40-iii
9.097.364
9.370.285
9.552.232
9.734.179
487
M-1-50-i
5.031.071
5.182.004
5.282.625
5.383.246
488
M-1-50-ii
9.097.364
9.370.285
9.552.232
9.734.179
489
M-1-50-iii
10.396.987
10.708.897
10.916.837
11.124.776
490
M-1-60-i
3.796.871
3.910.778
3.986.715
4.062.652
491
M-1-60-ii
7.601.361
7.829.402
7.981.429
8.133.457
492
M-1-60-iii
13.229.058
13.625.929
13.890.511
14.155.092
493
M-1-70-i
5.086.281
5.238.870
5.340.595
5.442.321
494
M-1-70-ii
10.378.533
10.689.888
10.897.459
11.105.030
495
M-1-70-iii
16.731.448
17.233.392
17.568.020
17.902.649
496
M-1-80-i
4.098.166
4.221.111
4.303.074
4.385.038
497
M-1-80-ii
6.195.589
6.381.457
6.505.368
6.629.280
498
M-1-80-iii
14.263.851
14.691.766
14.977.043
15.262.320
499
M-4-10-i
2.207.041
2.273.252
2.317.393
2.361.534
500
M-4-10-ii
3.959.954
4.078.753
4.157.952
4.237.151
501
M-4-10-iii
FRAKTUR FEMUR BERAT
8.408.754
8.661.016
8.829.191
8.997.366
502
M-4-11-i
3.434.902
3.537.949
3.606.647
3.675.345
503
M-4-11-ii
7.880.177
8.116.582
8.274.186
8.431.790
504
M-4-11-iii
13.987.130
14.406.744
14.686.486
14.966.229
505
M-4-12-i
1.929.531
1.987.417
2.026.008
2.064.598

TULANG WAJAH RINGAN
TULANG WAJAH SEDANG
TULANG WAJAH BERAT
SENDI MAYOR RINGAN
SENDI MAYOR SEDANG
SENDI MAYOR BERAT

RINGAN
SEDANG
BERAT

SELAIN KAKI (BERAT)

PANGGUL RINGAN
PANGGUL SEDANG
PANGGUL BERAT
PELVIS RINGAN
- 52 No
Kode
INA-CBG
506
M-4-12-ii
507
M-4-12-iii
508
M-4-13-i
509
M-4-13-ii
510
M-4-13-iii
511
M-4-14-i
512
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.510.780
3.616.103
3.686.319
3.756.534
7.718.125
7.949.668
8.104.031
8.258.393
4.791.369
4.935.110
5.030.937
5.126.764
5.363.967
5.524.886
5.632.166
5.739.445
14.253.121
14.680.715
14.965.777
15.250.840
3.859.062
3.974.834
4.052.015
4.129.197
M-4-14-ii
6.739.094
6.941.267
7.076.049
7.210.830
513
M-4-14-iii
OSTEOMIELITIS BERAT
8.746.498
9.008.893
9.183.823
9.358.753
514
M-4-15-i
3.238.525
3.335.681
3.400.451
3.465.222
515
M-4-15-ii
4.018.091
4.138.633
4.218.995
4.299.357
516
M-4-15-iii
9.033.592
9.304.600
9.485.272
9.665.944
517
M-4-16-i
3.235.396
3.332.458
3.397.166
3.461.874
518
M-4-16-ii
4.727.926
4.869.763
4.964.322
5.058.880
519
M-4-16-iii
9.651.984
9.941.544
10.134.583
10.327.623
520
M-4-17-i
2.771.894
2.855.051
2.910.489
2.965.927
521
M-4-17-ii
3.635.178
3.744.233
3.816.937
3.889.640
522
M-4-17-iii
4.987.692
5.137.323
5.237.076
5.336.830
523
M-4-18-i
3.802.789
3.916.873
3.992.929
4.068.985
524
M-4-18-ii
4.683.034
4.823.525
4.917.186
5.010.847
525
M-4-18-iii
6.449.309
6.642.788
6.771.774
6.900.761
526
M-4-19-i
2.827.425
2.912.248
2.968.797
3.025.345
527
M-4-19-ii
4.526.027
4.661.808
4.752.328
4.842.849
528
M-4-19-iii
7.222.171
7.438.836
7.583.280
7.727.723
529
M-4-20-i
2.107.874
2.171.110
2.213.267
2.255.425
530
M-4-20-ii
2.894.297
2.981.126
3.039.012
3.096.897
531
M-4-20-iii
3.207.563
3.303.790
3.367.941
3.432.092
532
M-4-21-i
2.019.861
2.080.457
2.120.854
2.161.252
533
M-4-21-ii
3.387.672
3.489.302
3.557.055
3.624.809
534
M-4-21-iii
6.994.550
7.204.387
7.344.278
7.484.169
535
N-1-01-i
5.273.352
5.431.552
5.537.019
5.642.486
536
N-1-01-ii
7.132.089
7.346.052
7.488.694
7.631.335

PELVIS SEDANG
PELVIS BERAT

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
RINGAN
SEDANG
BERAT
ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
- 53 No
Kode
INA-CBG
537
N-1-01-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
15.122.151
15.575.815
15.878.258
16.180.701
9.097.364
9.370.285
9.552.232
9.734.179
13.102.903
13.495.990
13.758.048
14.020.106
20.793.975
21.417.794
21.833.673
22.249.553
3.898.870
4.015.836
4.093.814
4.171.791
12.200.678
12.566.698
12.810.711
13.054.725
22.236.495
22.903.590
23.348.319
23.793.049
538
N-1-11-i
539
N-1-11-ii
540
N-1-11-iii
541
N-1-12-i
542
N-1-12-ii
543
N-1-12-iii
544
N-1-20-i
7.100.476
7.313.490
7.455.499
7.597.509
545
N-1-20-ii
14.077.719
14.500.050
14.781.604
15.063.159
546
N-1-20-iii
16.103.634
16.586.743
16.908.816
17.230.888
8.447.269
8.700.687
8.869.632
9.038.578
12.836.679
13.221.779
13.478.512
13.735.246
14.148.902
14.573.369
14.856.347
15.139.325
7.611.816
7.840.170
7.992.407
8.144.643
10.318.088
10.627.631
10.833.993
11.040.354
12.000.235
12.360.242
12.600.246
12.840.251
2.968.881
3.057.947
3.117.325
3.176.703
4.344.170
4.474.495
4.561.378
4.648.261
8.560.961
8.817.790
8.989.009
9.160.228


URIN BAWAH RINGAN
URIN BAWAH SEDANG
URIN BAWAH BERAT
RINGAN
SEDANG
BERAT
GINJAL RINGAN
GINJAL SEDANG
GINJAL BERAT
547
N-1-30-i
548
N-1-30-ii
549
N-1-30-iii
550
N-1-40-i
551
N-1-40-ii
552
N-1-40-iii
553
N-4-10-i
554
N-4-10-ii
555
N-4-10-iii
556
N-4-11-i
2.484.473
2.559.007
2.608.697
2.658.386
557
N-4-11-ii
4.198.699
4.324.660
4.408.634
4.492.608
558
N-4-11-iii
4.804.683
4.948.823
5.044.917
5.141.011
559
N-4-12-i
2.402.370
2.474.441
2.522.488
2.570.536
560
N-4-12-ii
3.376.466
3.477.760
3.545.289
3.612.818
561
N-4-12-iii
5.306.895
5.466.101
5.572.239
5.678.377
562
N-4-13-i
BATU URIN RINGAN
3.424.153
3.526.877
3.595.360
3.663.843
563
N-4-13-ii
BATU URIN SEDANG
4.128.240
4.252.088
4.334.652
4.417.217
564
N-4-13-iii
BATU URIN BERAT
10.166.724
10.471.725
10.675.060
10.878.394
565
N-4-14-i
1.688.158
1.738.803
1.772.566
1.806.329
566
N-4-14-ii
2.599.552
2.677.538
2.729.529
2.781.520

(RINGAN)
(SEDANG)
- 54 No
Kode
INA-CBG
567
N-4-14-iii
568
N-4-15-i
569
N-4-15-ii
570
N-4-15-iii
571
N-4-16-i
572
N-4-16-ii
573
N-4-16-iii
574
O-6-10-i
575
O-6-10-ii
576
O-6-10-iii
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
584
O-6-13-ii
585
O-6-13-iii
586
P-8-01-i
587
P-8-01-ii
588
P-8-01-iii
589
P-8-02-i
590
P-8-02-ii
591
P-8-02-iii
592
P-8-03-i
593
P-8-03-ii
594
P-8-03-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.215.644
4.342.113
4.426.426
4.510.739
3.335.249
3.435.307
3.502.012
3.568.717
4.577.000
4.714.310
4.805.850
4.897.390
5.223.183
5.379.878
5.484.342
5.588.806
3.349.652
3.450.141
3.517.134
3.584.127
4.322.644
4.452.323
4.538.776
4.625.229
8.621.464
8.880.108
9.052.537
9.224.967
4.166.347
4.291.337
4.374.664
4.457.991
4.625.280
4.764.038
4.856.544
4.949.050
5.699.912
5.870.909
5.984.907
6.098.906
2.630.270
2.709.178
2.761.784
2.814.389
4.285.481
4.414.046
4.499.756
4.585.465
7.262.561
7.480.438
7.625.689
7.770.940
2.908.872
2.996.138
3.054.316
3.112.493
3.493.548
3.598.355
3.668.226
3.738.096
4.389.143
4.520.817
4.608.600
4.696.383
2.061.289
2.123.128
2.164.354
2.205.580
2.408.092
2.480.335
2.528.497
2.576.659
2.994.782
3.084.625
3.144.521
3.204.416
48.969.191
50.438.267
51.417.650
52.397.034
60.591.714
62.409.465
63.621.299
64.833.134
71.117.686
73.251.217
74.673.571
76.095.924
79.009.457
81.379.740
82.959.930
84.540.119
90.631.980
93.350.939
95.163.579
96.976.218
103.553.517
106.660.122
108.731.193
110.802.263
3.249.059
3.346.530
3.411.511
3.476.493
4.839.352
4.984.533
5.081.320
5.178.107
8.794.927
9.058.775
9.234.674
9.410.572

(BERAT)
SALURAN URIN RINGAN
SALURAN URIN SEDANG
SALURAN URIN BERAT
RINGAN
SEDANG
BERAT
&KURET RINGAN
KURET SEDANG
KURET BERAT

- 55 No
Kode
INA-CBG
595
P-8-04-i
596
P-8-04-ii
597
P-8-04-iii
598
P-8-05-i
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii
603
P-8-06-iii
604
P-8-07-i
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
614
P-8-11-ii
615
P-8-11-iii
616
P-8-12-i
617
P-8-12-ii
618
P-8-12-iii
619
P-8-13-i
620
P-8-13-ii
621
P-8-13-iii
622
P-8-14-i
Deskripsi (INA-CBG)
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
RINGAN
SEDANG
BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
39.029.993
40.200.893
40.981.493
41.762.092
50.652.516
52.172.091
53.185.141
54.198.192
72.622.958
74.801.647
76.254.106
77.706.565
21.223.245
21.859.942
22.284.407
22.708.872
30.081.088
30.983.521
31.585.143
32.186.764
44.320.445
45.650.059
46.536.467
47.422.876
2.972.035
3.061.196
3.120.636
3.180.077
7.797.740
8.031.673
8.187.627
8.343.582
14.295.858
14.724.733
15.010.650
15.296.568
5.640.065
5.809.267
5.922.069
6.034.870
13.927.397
14.345.219
14.623.767
14.902.315
18.727.551
19.289.377
19.663.928
20.038.479
4.433.924
4.566.942
4.655.620
4.744.299
6.294.579
6.483.416
6.609.308
6.735.199
8.037.479
8.278.603
8.439.353
8.600.103
2.750.801
2.833.325
2.888.341
2.943.357
3.984.936
4.104.484
4.184.183
4.263.882
7.823.604
8.058.312
8.214.784
8.371.256
2.712.866
2.794.252
2.848.510
2.902.767
16.494.057
16.988.878
17.318.760
17.648.641
16.839.610
17.344.798
17.681.591
18.018.383
3.655.032
3.764.683
3.837.784
3.910.884
5.682.940
5.853.429
5.967.087
6.080.746
6.704.668
6.905.808
7.039.901
7.173.994
1.889.118
1.945.791
1.983.573
2.021.356
3.495.797
3.600.671
3.670.587
3.740.503
5.228.339
5.385.189
5.489.756
5.594.322
3.451.614
3.555.163
3.624.195
3.693.227
- 56 No
Kode
INA-CBG
623
P-8-14-ii
624
P-8-14-iii
625
P-8-15-i
626
P-8-15-ii
627
P-8-15-iii
628
P-8-16-i
629
P-8-16-ii
630
P-8-16-iii
631
P-8-17-i
632
P-8-17-ii
633
P-8-17-iii
634
S-4-10-i
635
S-4-10-ii
636
S-4-10-iii
637
S-4-11-i
638
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
7.047.220
7.258.636
7.399.581
7.540.525
7.730.774
7.962.697
8.117.312
8.271.928
2.595.722
2.673.593
2.725.508
2.777.422
5.188.165
5.343.810
5.447.573
5.551.337
6.094.303
6.277.132
6.399.018
6.520.904
2.349.742
2.420.234
2.467.229
2.514.223
3.333.209
3.433.205
3.499.869
3.566.533
4.326.669
4.456.469
4.543.002
4.629.536
1.548.009
1.594.449
1.625.409
1.656.369
5.151.314
5.305.853
5.408.879
5.511.906
10.397.598
10.709.526
10.917.478
11.125.430
1.929.531
1.987.417
2.026.008
2.064.598
2.411.914
2.484.271
2.532.510
2.580.748
3.135.074
3.229.126
3.291.828
3.354.529
1.205.957
1.242.136
1.266.255
1.290.374
S-4-11-ii
1.929.531
1.987.417
2.026.008
2.064.598
639
S-4-11-iii
2.969.501
3.058.586
3.117.976
3.177.366
640
S-4-12-i
1.487.339
1.531.959
1.561.706
1.591.452
641
S-4-12-ii
2.034.296
2.095.325
2.136.011
2.176.697
642
S-4-12-iii
3.891.807
4.008.561
4.086.398
4.164.234
643
S-4-13-i
2.311.564
2.380.911
2.427.142
2.473.373
644
S-4-13-ii
3.807.926
3.922.164
3.998.322
4.074.481
645
S-4-13-iii
7.377.715
7.599.047
7.746.601
7.894.155
646
S-4-14-i
1.187.464
1.223.088
1.246.837
1.270.586
647
S-4-14-ii
2.522.572
2.598.249
2.648.700
2.699.152
648
S-4-14-iii
4.783.695
4.927.206
5.022.880
5.118.553
649
S-4-15-i
898.090
925.033
942.994
960.956
650
S-4-15-ii
1.695.002
1.745.852
1.779.752
1.813.652
651
S-4-15-iii
2.195.421
2.261.284
2.305.192
2.349.100
652
S-4-16-i
LUKA BAKAR RINGAN
3.686.874
3.797.481
3.871.218
3.944.956
653
S-4-16-ii
LUKA BAKAR SEDANG
6.414.755
6.607.197
6.735.492
6.863.787
654
S-4-16-iii
LUKA BAKAR BERAT
11.454.540
11.798.176
12.027.267
12.256.358

ASPIRASI RINGAN
ASPIRASI SEDANG
ASPIRASI BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT

PASIEN RINGAN
PASIEN SEDANG
PASIEN BERAT
- 57 No
Kode
INA-CBG
655
S-4-17-i
656
S-4-17-ii
657
S-4-17-iii
658
T-1-10-i
659
T-1-10-ii
660
T-1-10-iii
661
T-4-10-i
662
T-4-10-ii
663
T-4-10-iii
664
T-4-11-i
665
T-4-11-ii
666
T-4-11-iii
667
T-4-12-i
668
T-4-12-ii
669
T-4-12-iii
670
U-1-10-i
671
672
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.421.872
2.494.529
2.542.966
2.591.404
2.820.520
2.905.136
2.961.546
3.017.956
4.357.023
4.487.734
4.574.874
4.662.014
4.855.114
5.000.767
5.097.869
5.194.972
6.520.088
6.715.691
6.846.093
6.976.494
11.862.166
12.218.031
12.455.274
12.692.517
1.594.784
1.642.627
1.674.523
1.706.418
3.039.304
3.130.483
3.191.269
3.252.055
4.418.323
4.550.872
4.639.239
4.727.605
2.100.282
2.163.291
2.205.296
2.247.302
3.305.246
3.404.404
3.470.509
3.536.614
5.323.778
5.483.492
5.589.967
5.696.443
3.456.547
3.560.244
3.629.375
3.698.506
5.150.346
5.304.856
5.407.863
5.510.870
7.931.653
8.169.603
8.328.236
8.486.869
1.815.176
1.869.631
1.905.935
1.942.238
U-1-10-ii
3.703.978
3.815.097
3.889.177
3.963.256
U-1-10-iii
15.994.525
16.474.360
16.794.251
17.114.141

DOKTER RINGAN
DOKTER SEDANG
DOKTER BERAT

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
7.797.740
8.031.673
8.187.627
8.343.582
10.396.987
10.708.897
10.916.837
11.124.776
23.496.065
24.200.947
24.670.868
25.140.789
673
U-1-11-i
674
U-1-11-ii
675
U-1-11-iii
676
U-1-12-i
6.409.794
6.602.088
6.730.283
6.858.479
677
U-1-12-ii
11.696.611
12.047.509
12.281.441
12.515.373
678
U-1-12-iii
15.188.270
15.643.919
15.947.684
16.251.449
679
U-1-13-i
5.198.494
5.354.448
5.458.418
5.562.388
680
U-1-13-ii
6.498.117
6.693.061
6.823.023
6.952.985
681
U-1-13-iii
11.309.974
11.649.274
11.875.473
12.101.673
3.858.245
3.973.992
4.051.157
4.128.322
4.734.842
4.876.888
4.971.584
5.066.281
5.610.921
5.779.249
5.891.467
6.003.686
2.266.094
2.334.077
2.379.399
2.424.721
682
U-1-14-i
683
U-1-14-ii
684
U-1-14-iii
685
U-1-15-i

- 58 No
Kode
INA-CBG
686
U-1-15-ii
687
U-1-15-iii
688
U-1-20-i
689
U-1-20-ii
690
U-1-20-iii
691
U-1-30-i
692
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.219.962
3.316.561
3.380.960
3.445.359
6.345.064
6.535.416
6.662.317
6.789.219
5.861.399
6.037.241
6.154.469
6.271.697
9.213.909
9.490.327
9.674.605
9.858.883
19.135.576
19.709.643
20.092.355
20.475.066
5.028.058
5.178.900
5.279.461
5.380.022
U-1-30-ii
6.787.878
6.991.515
7.127.272
7.263.030
693
U-1-30-iii
10.396.987
10.708.897
10.916.837
11.124.776
694
U-4-10-i
4.680.282
4.820.691
4.914.296
5.007.902
695
U-4-10-ii
11.732.485
12.084.459
12.319.109
12.553.759
696
U-4-10-iii
17.115.140
17.628.595
17.970.898
18.313.200
697
U-4-11-i
2.172.018
2.237.178
2.280.619
2.324.059
698
U-4-11-ii
2.894.297
2.981.126
3.039.012
3.096.897
699
U-4-11-iii
5.384.177
5.545.702
5.653.385
5.761.069
700
U-4-12-i
1.929.531
1.987.417
2.026.008
2.064.598
701
U-4-12-ii
3.025.658
3.116.428
3.176.941
3.237.454
702
U-4-12-iii
4.810.659
4.954.979
5.051.192
5.147.405
703
U-4-13-i
1.929.531
1.987.417
2.026.008
2.064.598
704
U-4-13-ii
2.203.772
2.269.885
2.313.960
2.358.036
705
U-4-13-iii
3.365.744
3.466.716
3.534.031
3.601.346
706
U-4-14-i
2.411.914
2.484.271
2.532.510
2.580.748
707
U-4-14-ii
2.894.297
2.981.126
3.039.012
3.096.897
708
U-4-14-iii
4.879.183
5.025.558
5.123.142
5.220.726
2.078.375
2.140.726
2.182.294
2.223.861
2.737.136
2.819.250
2.873.992
2.928.735
3.712.275
3.823.644
3.897.889
3.972.135
6.411.311
6.603.651
6.731.877
6.860.103
7.277.402
7.495.724
7.641.272
7.786.820
12.346.422
12.716.815
12.963.744
13.210.672


DAN TELINGA RINGAN
DAN TELINGA SEDANG
DAN TELINGA BERAT


KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT
709
U-4-15-i
710
U-4-15-ii
711
U-4-15-iii
712
V-1-10-i
713
V-1-10-ii
714
V-1-10-iii
715
V-1-11-i
6.498.117
6.693.061
6.823.023
6.952.985
716
V-1-11-ii
7.252.008
7.469.568
7.614.608
7.759.648
717
V-1-11-iii
10.739.113
11.061.286
11.276.069
11.490.851
718
V-1-12-i

4.720.644
4.862.264
4.956.677
5.051.090
- 59 No
Kode
INA-CBG
719
V-1-12-ii
720
V-1-12-iii
721
V-1-13-i
722
V-1-13-ii
723
V-1-13-iii
724
V-1-14-i
725
V-1-14-ii
726
V-1-14-iii
727
V-1-15-i
728
V-1-15-ii
729
V-1-15-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
14.410.510
14.842.825
15.131.035
15.419.245
16.206.508
16.692.703
17.016.833
17.340.963
7.154.967
7.369.616
7.512.715
7.655.814
13.596.490
14.004.385
14.276.314
14.548.244
15.595.481
16.063.345
16.375.255
16.687.165
8.625.395
8.884.157
9.056.665
9.229.173
12.544.899
12.921.246
13.172.144
13.423.042
16.973.737
17.482.949
17.822.423
18.161.898
3.898.870
4.015.836
4.093.814
4.171.791
6.084.443
6.266.976
6.388.665
6.510.354
10.123.224
10.426.921
10.629.385
10.831.850
6.547.920
6.744.358
6.875.316
7.006.275
8.457.421
8.711.144
8.880.292
9.049.441
16.163.617
16.648.525
16.971.797
17.295.070
3.329.863
3.429.759
3.496.356
3.562.953
4.865.462
5.011.425
5.108.735
5.206.044
8.027.689
8.268.520
8.429.074
8.589.628
9.791.427
10.085.170
10.280.999
10.476.827
11.793.310
12.147.109
12.382.975
12.618.841
21.353.972
21.994.591
22.421.671
22.848.750

NON KOMPLEK (BERAT)

RINGAN
SEDANG
BERAT
730
V-4-10-i
731
V-4-10-ii
732
V-4-10-iii
733
V-4-11-i
734
V-4-11-ii
735
V-4-11-iii
736
W-1-01-i
737
W-1-01-ii
738
W-1-01-iii
739
W-1-10-i
2.599.247
2.677.224
2.729.209
2.781.194
740
W-1-10-ii
5.088.844
5.241.509
5.343.286
5.445.063
741
W-1-10-iii
8.323.734
8.573.446
8.739.921
8.906.396
742
W-1-11-i
2.832.343
2.917.313
2.973.960
3.030.607
743
W-1-11-ii
5.198.494
5.354.448
5.458.418
5.562.388
744
W-1-11-iii
7.797.740
8.031.673
8.187.627
8.343.582
745
W-1-12-i
2.573.609
2.650.818
2.702.290
2.753.762
746
W-1-12-ii
2.926.144
3.013.929
3.072.452
3.130.975
747
W-1-12-iii
4.494.927
4.629.775
4.719.673
4.809.572
748
W-1-13-i
2.300.229
2.369.236
2.415.240
2.461.245
749
W-1-13-ii
2.497.386
2.572.307
2.622.255
2.672.203
750
W-1-13-iii
3.354.450
3.455.083
3.522.172
3.589.261

SERVIK RINGAN
SERVIK SEDANG
SERVIK BERAT
ENDOSKOP RINGAN
ENDOSKOP SEDANG
ENDOSKOP BERAT
- 60 No
Kode
INA-CBG
751
W-1-20-i
752
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
8.346.356
8.596.747
8.763.674
8.930.601
W-1-20-ii
10.396.987
10.708.897
10.916.837
11.124.776
753
W-1-20-iii
11.696.611
12.047.509
12.281.441
12.515.373
754
W-1-30-i
4.556.274
4.692.962
4.784.087
4.875.213
755
W-1-30-ii
6.498.117
6.693.061
6.823.023
6.952.985
756
W-1-30-iii
19.326.050
19.905.831
20.292.352
20.678.873
757
W-4-10-i
3.397.839
3.499.774
3.567.731
3.635.687
758
W-4-10-ii
4.592.560
4.730.336
4.822.188
4.914.039
759
W-4-10-iii
8.255.644
8.503.313
8.668.426
8.833.539
760
W-4-11-i
2.411.914
2.484.271
2.532.510
2.580.748
761
W-4-11-ii
4.047.649
4.169.079
4.250.032
4.330.985
762
W-4-11-iii
4.886.856
5.033.462
5.131.199
5.228.936
763
W-4-12-i
1.929.531
1.987.417
2.026.008
2.064.598
764
W-4-12-ii
3.297.843
3.396.779
3.462.736
3.528.693
765
W-4-12-iii
3.978.702
4.098.063
4.177.637
4.257.211
766
W-4-13-i
ABORTUS RINGAN
1.058.178
1.089.923
1.111.087
1.132.250
767
W-4-13-ii
ABORTUS SEDANG
1.447.148
1.490.563
1.519.506
1.548.449
768
W-4-13-iii
ABORTUS BERAT
1.929.531
1.987.417
2.026.008
2.064.598
769
W-4-14-i
1.447.148
1.490.563
1.519.506
1.548.449
770
W-4-14-ii
1.929.531
1.987.417
2.026.008
2.064.598
771
W-4-14-iii
2.342.043
2.412.304
2.459.145
2.505.986
772
W-4-15-i
1.447.148
1.490.563
1.519.506
1.548.449
773
W-4-15-ii
1.555.324
1.601.984
1.633.091
1.664.197
774
W-4-15-iii
1.967.761
2.026.794
2.066.149
2.105.504
775
W-4-16-i
1.628.532
1.677.388
1.709.959
1.742.529
776
W-4-16-ii
2.580.097
2.657.500
2.709.102
2.760.704
777
W-4-16-iii
3.288.278
3.386.926
3.452.692
3.518.458
778
W-4-17-i
1.447.148
1.490.563
1.519.506
1.548.449
779
W-4-17-ii
1.929.531
1.987.417
2.026.008
2.064.598
780
W-4-17-iii
3.650.289
3.759.798
3.832.804
3.905.809
781
Z-4-10-i
REHABILITASI RINGAN
6.494.444
6.689.277
6.819.166
6.949.055
782
Z-4-10-ii
REHABILITASI SEDANG
8.620.437
8.879.050
9.051.459
9.223.867
783
Z-4-10-iii
REHABILITASI BERAT
12.246.153
12.613.537
12.858.460
13.103.383
784
Z-4-11-i
3.887.353
4.003.973
4.081.720
4.159.467

RINGAN
SEDANG
BERAT

- 61 No
Kode
INA-CBG
Deskripsi (INA-CBG)
785
Z-4-11-ii
786
Z-4-11-iii
787
Z-4-12-i
788
Z-4-12-ii
789
Z-4-12-iii
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.679.513
4.819.899
4.913.489
5.007.079
7.315.775
7.535.248
7.681.564
7.827.879
1.503.534
1.548.640
1.578.710
1.608.781
3.966.057
4.085.039
4.164.360
4.243.681
5.040.231
5.191.438
5.292.242
5.393.047

b. RawatJalan
No
Kode
INA-CBG
- 62 -
Deskripsi (INA-CBG)
B-2-10-0
B-2-11-0

LAPAROSKOPI
PANKREAS
LAPAROSKOPI
EMPEDU
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
800.166
824.171
840.174
856.178
1.037.940
1.069.079
1.089.837
1.110.596
1.930.187
1.988.093
2.026.696
2.065.300
1.595.112
1.642.966
1.674.868
1.706.770
1.332.579
1.372.556
1.399.208
1.425.859
467.208
481.224
490.568
499.913
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
1.041.813
1.073.067
1.093.903
1.114.739
B-3-12-0

214.058
220.480
224.761
229.042
C-3-10-0
583.921
601.438
613.117
624.795
10
C-3-11-0
KEMOTERAPI PADA TUMOR PARU & KANDUNG

KEMIH
923.492
951.197
969.667
988.137
11
C-3-12-0
209.354
215.634
219.822
224.009
12
C-3-13-0
203.297
209.396
213.462
217.528
13
C-3-14-0
1.730.670
1.782.590
1.817.203
1.851.817
14
C-3-15-0
1.586.228
1.633.815
1.665.539
1.697.264
15
C-3-16-0
359.718
370.510
377.704
384.899
16
C-3-17-0

LEHER
238.627
245.785
250.558
255.330
17
C-3-18-0
105.797
108.971
111.087
113.202
18
C-3-19-0

MYELOMA ATAU TESTIS
149.618
154.107
157.099
160.091
19
C-3-20-0
2.979.648
3.069.038
3.128.631
3.188.224
20
C-3-21-0
170.741
175.863
179.278
182.693
21
C-3-22-0
749.644
772.133
787.126
802.119
22
C-3-23-0
121.426
125.069
127.497
129.926
23
D-2-10-0
PROSEDUR PENCANGKOKAN SUMSUM TULANG
1.028.737
1.059.599
1.080.174
1.100.749
24
D-2-11-0
PROSEDUR LIMPA
1.288.155
1.326.799
1.352.563
1.378.326
1.080.397
1.112.809
1.134.417
1.156.025
237.115
244.228
248.970
253.713
171.748
176.900
180.335
183.770
445.907
459.284
468.203
477.121
264.509
272.444
277.734
283.024
191.760
197.513
201.348
205.183
191.760
197.513
201.348
205.183
25
D-2-21-0
26
D-2-22-0
27
D-3-10-0
28
D-3-11-0
29
E-2-10-0
30
E-2-21-0
31
E-2-22-0

OVARIUM
GASTROINTESTINAL
GINJAL ATAU PROSTAT

TYMUS
TYMUS
TULANG
PEMBENTUK DARAH
PARATIROID
THYROGLOSSAL
- 63 No
Kode
INA-CBG
32
E-3-10-0
33
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

ENDOKRIN
223.004
229.694
234.155
238.615
F-3-10-0
TERAPI SHOCK
713.639
735.048
749.321
763.594
34
F-5-10-0
874.439
900.672
918.161
935.650
35
F-5-11-0
TERAPI KELOMPOK
576.612
593.910
605.443
616.975
36
F-5-12-0
737.873
760.009
774.767
789.524
37
F-5-13-0
624.929
643.677
656.176
668.674
38
F-5-14-0
419.244
431.821
440.206
448.591
39
F-5-15-0
393.305
405.104
412.970
420.836
40
F-5-16-0
409.665
421.955
430.148
438.341
41
G-2-10-0
PROSEDUR KRANIOTOMI
150.376
154.887
157.895
160.903
42
G-2-11-0
1.303.524
1.342.630
1.368.700
1.394.771
43
G-2-12-0

EKSTRAKRANIAL
1.889.128
1.945.801
1.983.584
2.021.366
44
G-2-13-0
463.445
477.348
486.617
495.886
45
G-2-21-0
845.246
870.603
887.508
904.413
46
G-2-22-0
767.132
790.146
805.489
820.832
47
G-2-31-0
1.265.835
1.303.810
1.329.127
1.354.444
48
G-2-32-0
648.866
668.332
681.309
694.287
49
G-3-10-0
257.539
265.265
270.416
275.567
50
G-3-11-0
342.993
353.282
360.142
367.002
51
G-3-12-0
561.999
578.859
590.099
601.339
52
G-3-13-0
562.063
578.925
590.167
601.408
53
H-2-21-0
737.625
759.754
774.506
789.259
54
H-2-22-0
191.760
197.513
201.348
205.183
55
H-2-23-0
191.760
197.513
201.348
205.183
56
H-2-31-0
1.221.814
1.258.469
1.282.905
1.307.341
57
H-2-32-0
127.162
130.977
133.520
136.064
58
H-2-33-0
191.760
197.513
201.348
205.183
59
H-2-34-0
548.136
564.580
575.542
586.505
60
H-2-35-0
180.623
186.042
189.654
193.267
61
H-2-36-0
974.961
1.004.210
1.023.710
1.043.209
62
H-2-37-0

1.037.889
1.069.026
1.089.784
1.110.542
63
H-3-10-0
361.110
371.943
379.165
386.387
64
H-3-11-0
189.904
195.601
199.399
203.197

AKUT
MENTAL
PSIKOTHERAPI INDIVIDU PADA KANAK-KANAK
MASALAH KESEHATAN MENTAL

MATA
MATA
MATA
MATA
MATA
- 64 No
Kode
INA-CBG
65
H-3-12-0
66
H-3-13-0
67
I-2-11-0
68
I-2-12-0
69
I-2-13-0
70
I-2-14-0
71
I-2-15-0
Deskripsi (INA-CBG)
MATA
TORASIK
ABDOMEN
PENGGANTIAN ALAT
DARAH VENA
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
198.269
204.217
208.183
212.148
192.507
198.283
202.133
205.983
2.220.020
2.286.620
2.331.021
2.375.421
1.560.916
1.607.744
1.638.962
1.670.180
1.983.831
2.043.345
2.083.022
2.122.699
3.510.958
3.616.286
3.686.505
3.756.725
211.142
217.476
221.699
225.922
2.217.614
2.284.142
2.328.495
2.372.847
731.084
753.016
767.638
782.259
72
I-2-16-0
73
I-2-17-0
74
I-2-21-0
1.711.683
1.763.033
1.797.267
1.831.500
75
I-2-22-0
1.611.849
1.660.204
1.692.441
1.724.678
76
I-2-23-0
329.860
339.756
346.353
352.950
77
I-2-31-0
2.565.433
2.642.396
2.693.705
2.745.014
78
I-2-32-0
3.354.681
3.455.321
3.522.415
3.589.508
79
I-2-41-0
2.249.355
2.316.835
2.361.822
2.406.809
80
I-2-42-0

LAIN
2.615.247
2.693.704
2.746.009
2.798.314
81
I-3-10-0
PROSEDUR RESUSITASI
331.982
341.942
348.581
355.221
82
I-3-11-0
175.220
180.476
183.981
187.485
83
I-3-12-0
1.018.310
1.048.859
1.069.225
1.089.591
84
I-3-13-0
334.452
344.486
351.175
357.864
85
I-3-14-0
214.373
220.804
225.091
229.379
189.904
195.601
199.399
203.197
1.175.761
1.211.034
1.234.549
1.258.065
189.532
195.218
199.009
202.800
955.125
983.779
1.002.882
1.021.984
1.238.883
1.276.050
1.300.827
1.325.605

PACU JANTUNG

KARDIOVASKULAR
PERNAFASAN
PENDEK
86
I-3-15-0
87
J-2-10-0
88
J-2-21-0
89
J-2-22-0
90
J-2-31-0
PROSEDUR THORAKOSKOPI/MEDIASTINOSKOPI
91
J-2-32-0
921.935
949.593
968.031
986.470
92
J-3-10-0
191.760
197.513
201.348
205.183
93
J-3-11-0

PADA DADA
541.879
558.136
568.973
579.811
94
J-3-12-0
209.354
215.634
219.822
224.009
95
J-3-13-0
308.117
317.360
323.522
329.685
96
J-3-14-0
327.099
336.912
343.454
349.996
- 65 No
Kode
INA-CBG
97
J-3-15-0
98
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
286.840
295.445
301.182
306.919
J-3-16-0
327.099
336.912
343.454
349.996
99
J-3-17-0

PERNAFASAN
191.760
197.513
201.348
205.183
100
K-2-10-0
PROSEDUR KECIL PADA USUS BESAR DAN KECIL
551.950
568.509
579.548
590.587
101
K-2-11-0
1.178.639
1.213.999
1.237.571
1.261.144
102
K-2-12-0

904.758
931.900
949.996
968.091
103
K-2-13-0
1.472.542
1.516.718
1.546.169
1.575.620
104
K-2-14-0
191.760
197.513
201.348
205.183
105
K-2-21-0
191.760
197.513
201.348
205.183
106
K-2-22-0
2.464.571
2.538.508
2.587.799
2.637.091
107
K-2-31-0
828.710
853.571
870.145
886.719
108
K-2-32-0
191.760
197.513
201.348
205.183
109
K-2-41-0
912.841
940.226
958.483
976.740
110
K-2-42-0
PROSEDUR LAPAROTOMI & GASTROINTESTINAL

LAINNYA
260.810
268.634
273.850
279.067
111
K-2-51-0
604.904
623.051
635.149
647.247
112
K-2-52-0
329.860
339.756
346.353
352.950
113
K-2-53-0
191.760
197.513
201.348
205.183
114
K-3-10-0

GASTROINTESTINAL
364.906
375.853
383.151
390.450
115
K-3-11-0
219.380
225.961
230.349
234.736
116
K-3-12-0
222.479
229.153
233.603
238.052
117
K-3-13-0
191.760
197.513
201.348
205.183
118
K-3-14-0
513.921
529.338
539.617
549.895
119
K-3-15-0
248.179
255.625
260.588
265.552
120
K-3-16-0
328.854
338.719
345.296
351.873
121
L-2-21-0
1.130.610
1.164.529
1.187.141
1.209.753
122
L-2-22-0
724.713
746.455
760.949
775.443
123
L-2-31-0
327.099
336.912
343.454
349.996
124
L-2-32-0
329.860
339.756
346.353
352.950
125
L-2-41-0
987.727
1.017.359
1.037.113
1.056.868
126
L-2-42-0

221.531
228.177
232.608
237.038
127
L-2-51-0
1.478.782
1.523.145
1.552.721
1.582.297
128
L-2-52-0
1.131.317
1.165.256
1.187.883
1.210.509
129
L-2-53-0
191.760
197.513
201.348
205.183

FEMORALIS
USUS BESAR
ATAS
ATAS

GASTROINTESTINAL
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR

- 66 No
Kode
INA-CBG
130
L-3-10-0
131
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
260.810
268.634
273.850
279.067
L-3-11-0
253.264
260.862
265.928
270.993
132
L-3-12-0
192.885
198.672
202.529
206.387
133
M-2-10-0
1.512.902
1.558.289
1.588.547
1.618.805
134
M-2-21-0
1.354.908
1.395.555
1.422.653
1.449.752
135
M-2-22-0
329.860
339.756
346.353
352.950
136
M-2-31-0
PROSEDUR BUNION
822.971
847.660
864.119
880.578
137
M-2-32-0
260.810
268.634
273.850
279.067
138
M-2-41-0

TULANG
260.810
268.634
273.850
279.067
139
M-2-42-0
89.882
92.579
94.376
96.174
140
M-2-51-0
191.760
197.513
201.348
205.183
141
M-2-52-0
191.760
197.513
201.348
205.183
142
M-2-61-0
PROSEDUR ARTROSKOPI
939.915
968.113
986.911
1.005.709
143
M-2-62-0
191.760
197.513
201.348
205.183
945.000
973.350
992.250
1.011.150
1.288.785
1.327.448
1.353.224
1.379.000
191.760
197.513
201.348
205.183
951.462
980.006
999.035
1.018.064
918.201
945.747
964.111
982.475

DAN WAJAH
PAHA
PAHA

TULANG
WAJAH
WAJAH
BAWAH
BAWAH
144
M-2-63-0
145
M-2-64-0
146
M-2-65-0
147
M-2-71-0
148
M-2-72-0
149
M-2-81-0
1.369.234
1.410.311
1.437.695
1.465.080
150
M-2-82-0
994.660
1.024.500
1.044.393
1.064.287
151
M-2-83-0
191.760
197.513
201.348
205.183
152
M-2-84-0
191.760
197.513
201.348
205.183
153
M-3-10-0
547.320
563.739
574.686
585.632
154
M-3-11-0

MUSKULOSKELETAL
303.455
312.559
318.628
324.697
155
M-3-12-0
PROSEDUR BIOPSI SENDI DAN TRAKSI SKELETAL
686.241
706.828
720.553
734.278
156
M-3-13-0
223.733
230.445
234.920
239.394
157
M-3-14-0

TERTUTUP
382.398
393.870
401.517
409.165
158
M-3-15-0
168.470
173.524
176.893
180.262
159
M-3-16-0
PROSEDUR THERAPI FISIK DAN PROSEDUR KECIL

MUSKULOSKLETAL
191.760
197.513
201.348
205.183
160
M-3-17-0
209.354
215.634
219.822
224.009
161
N-2-11-0
2.533.336
2.609.336
2.660.002
2.710.669
N-2-12-0

1.465.510
1.509.475
1.538.785
1.568.095
162

PERGELANGAN TANGAN
PERGELANGAN TANGAN
- 67 No
Kode
INA-CBG
163
N-2-21-0

164
N-2-22-0
165
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.457.785
1.501.518
1.530.674
1.559.830
329.860
339.756
346.353
352.950
N-2-23-0
329.860
339.756
346.353
352.950
166
N-2-24-0
1.065.997
1.097.977
1.119.297
1.140.617
167
N-2-31-0
897.397
924.319
942.267
960.214
168
N-2-32-0
329.860
339.756
346.353
352.950
169
N-2-41-0
329.860
339.756
346.353
352.950
170
N-2-42-0
557.857
574.592
585.749
596.907
171
N-3-10-0
329.860
339.756
346.353
352.950
172
N-3-11-0
382.190
393.656
401.300
408.943
173
N-3-12-0
295.335
304.195
310.102
316.008
174
N-3-13-0
329.860
339.756
346.353
352.950
175
N-3-14-0
283.827
292.341
298.018
303.695
176
N-3-15-0
727.803
749.637
764.193
778.749
177
O-7-10-0
121.512
125.157
127.587
130.018
178
O-7-11-0
669.197
689.273
702.657
716.041
179
O-7-12-0
243.677
250.988
255.861
260.735
180
O-7-13-0
135.425
139.488
142.196
144.905
181
P-9-10-0
180.623
186.042
189.654
193.267
182
P-9-11-0
180.623
186.042
189.654
193.267
183
P-9-12-0
180.623
186.042
189.654
193.267
184
P-9-13-0
180.623
186.042
189.654
193.267
180.623
186.042
189.654
193.267
115.133
118.587
120.890
123.192
180.623
186.042
189.654
193.267
PROSEDUR BESAR PADA KANDUNG KEMIH DAN

URETHRA
URETHRA
TRANSURETHRA
TRANSURETHRA
SALURAN KEMIH
KEMIH
KEMIH
PROSEDUR DIALISIS
CAESAR
VAGINAL/JALAN LAHIR

ASPIRASI
185
P-9-14-0
186
P-9-15-0
187
P-9-16-0
188
P-9-17-0
179.846
185.242
188.839
192.436
189
Q-5-10-0
540.039
556.240
567.041
577.842
190
Q-5-11-0
404.745
416.887
424.982
433.077
191
Q-5-12-0
GIGI
356.731
367.433
374.568
381.703
192
Q-5-13-0
MEDICAL CHECK-UP
271.100
279.233
284.655
290.077
193
Q-5-14-0
298.299
307.248
313.214
319.180
194
Q-5-15-0
205.140
211.294
215.397
219.500
- 68 No
Kode
INA-CBG
195
Q-5-16-0
196
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
VAKSINASI
231.856
238.811
243.448
248.085
Q-5-17-0
PASANG INFUS
200.549
206.565
210.576
214.587
197
Q-5-18-0
377.496
388.821
396.371
403.921
198
Q-5-19-0
422.018
434.678
443.119
451.559
199
Q-5-20-0
ABORSI MENGANCAM
282.865
291.351
297.008
302.665
200
Q-5-21-0
ABORSI
279.012
287.383
292.963
298.543
201
Q-5-22-0
298.299
307.248
313.214
319.180
202
Q-5-23-0
365.197
376.152
383.456
390.760
203
Q-5-24-0
249.424
256.907
261.895
266.884
204
Q-5-25-0
388.972
400.641
408.420
416.200
205
Q-5-26-0
BRONKIAL AKUT
550.563
567.079
578.091
589.102
206
Q-5-27-0
391.807
403.562
411.398
419.234
207
Q-5-28-0
317.941
327.480
333.839
340.197
208
Q-5-29-0

JANTUNG LAIN-LAIN
900.144
927.149
945.152
963.155
209
Q-5-30-0
1.043.170
1.074.465
1.095.329
1.116.192
210
Q-5-31-0
FRAKTUR
372.161
383.326
390.769
398.213
211
Q-5-32-0
SALURAN KEMIH AKUT
431.047
443.978
452.599
461.220
212
Q-5-33-0
HEMATOLOGI AKUT
451.304
464.844
473.870
482.896
213
Q-5-34-0
INFEKSI VIRUS HIV
641.109
660.343
673.165
685.987
214
Q-5-35-0
INFEKSI AKUT
727.001
748.811
763.351
777.891
215
Q-5-36-0
846.640
872.039
888.972
905.904
216
Q-5-37-0

SHOCK
431.829
444.784
453.421
462.057
217
Q-5-38-0
PARU AKUT
575.859
593.134
604.652
616.169
218
Q-5-39-0
368.507
379.562
386.932
394.302
219
Q-5-40-0
361.564
372.411
379.643
386.874
220
Q-5-41-0
500.535
515.551
525.562
535.572
221
Q-5-42-0
392.439
404.212
412.061
419.910
222
Q-5-43-0
565.135
582.089
593.392
604.694
223
Q-5-44-0
461.229
475.065
484.290
493.515
224
T-2-10-0

TERAPI DETOKSIKASI
3.608.440
3.716.693
3.788.862
3.861.031
225
U-2-10-0
1.391.785
1.433.539
1.461.375
1.489.210
226
U-2-11-0

LEHER
1.654.292
1.703.920
1.737.006
1.770.092
227
U-2-12-0
182.015
187.476
191.116
194.756
228
U-2-13-0
238.627
245.785
250.558
255.330
- 69 No
Kode
INA-CBG
229
U-2-14-0
230
U-2-15-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
443.260
456.558
465.423
474.288
251.851
259.406
264.443
269.480
293.367
302.168
308.035
313.902
566.808
583.812
595.148
606.484

231
U-2-21-0
232
U-2-22-0
233
U-2-23-0
PROSEDUR PERBAIKAN HIDUNG (RHINOPLASTY)
742.701
764.982
779.836
794.690
234
U-2-24-0
625.936
644.714
657.233
669.751
235
U-2-25-0
238.627
245.785
250.558
255.330
236
U-2-31-0
191.760
197.513
201.348
205.183
237
U-2-32-0
238.627
245.785
250.558
255.330
238
U-3-10-0
228.140
234.984
239.546
244.109
239
U-3-11-0
242.213
249.479
254.324
259.168
240
U-3-12-0
107.106
110.319
112.462
114.604
241
U-3-13-0
235.428
242.491
247.199
251.908
242
U-3-14-0
216.310
222.799
227.125
231.451
243
U-3-15-0
188.641
194.301
198.073
201.846
244
U-3-16-0
PROSEDUR PADA GIGI
212.753
219.136
223.391
227.646
245
V-2-10-0

PROSTAT
2.075.654
2.137.923
2.179.436
2.220.949
246
V-2-11-0
PROSEDUR PADA PENIS
234.081
241.103
245.785
250.467
247
V-2-12-0
746.986
769.395
784.335
799.275
248
V-2-13-0
329.860
339.756
346.353
352.950
249
V-2-14-0
329.860
339.756
346.353
352.950
250
V-2-15-0
SIRKUMSISI/SUNAT
180.623
186.042
189.654
193.267
251
V-3-10-0
376.702
388.003
395.537
403.071
796.919
820.827
836.765
852.704
460.083
473.885
483.087
492.288
168.470
173.524
176.893
180.262
430.545
443.462
452.073
460.684
796.919
820.827
836.765
852.704
127.812
131.646
134.202
136.758
1.602.020
1.650.081
1.682.121
1.714.162
168.470
173.524
176.893
180.262
562.191
579.057
590.301
601.545
252
V-3-11-0
253
V-3-12-0
254
W-2-10-0
255
W-2-11-0
256
W-2-12-0
257
W-2-13-0
258
W-2-21-0
259
W-2-22-0
260
W-2-23-0

RONGGA HIDUNG
TELINGA, HIDUNG, MULUT DAN TENGGOROKAN
PROSEDUR LAIN-LAIN PADA TELINGA, HIDUNG,

SKROTUM
SKROTUM
TRANSURETHRAL

PROSEDUR ABORSI
RAHIM & LEHER RAHIM
TERHALANG/TERGANGGU
TERHALANG/TERGANGGU
PANGGUL TERBUKA
PANGGUL TERBUKA
- 70 No
Kode
INA-CBG
261
W-2-31-0
262
W-2-32-0
263
W-2-33-0
264
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.845.502
1.900.867
1.937.777
1.974.688
1.294.335
1.333.165
1.359.051
1.384.938
550.109
566.613
577.615
588.617
W-2-34-0
187.102
192.715
196.457
200.199
265
W-3-10-0
454.730
468.372
477.466
486.561
266
W-3-11-0
363.498
374.403
381.673
388.943
267
W-3-12-0
168.470
173.524
176.893
180.262
268
Z-3-10-0
1.907.300
1.964.519
2.002.665
2.040.811
269
Z-3-11-0

(ESWL) SELAIN URINARI DAN SALURAN EMPEDU
1.457.785
1.501.518
1.530.674
1.559.830
270
Z-3-12-0
558.404
575.156
586.324
597.492
271
Z-3-13-0

LAIN-LAIN
1.485.384
1.529.945
1.559.653
1.589.361
272
Z-3-14-0
DIAGNOSTIK TIDUR
673.775
693.988
707.464
720.939
273
Z-3-15-0
191.760
197.513
201.348
205.183
274
Z-3-16-0

(MRI)
615.491
633.956
646.265
658.575
275
Z-3-17-0
PENGOBATAN NUKLIR
258.396
266.148
271.316
276.484
276
Z-3-18-0
CT-SCAN KEPALA
248.960
256.429
261.408
266.387
277
Z-3-19-0
CT SCAN LAIN-LAIN
259.119
266.892
272.075
277.257
278
Z-3-20-0
176.233
181.520
185.045
188.569
279
Z-3-21-0
168.470
173.524
176.893
180.262
280
Z-3-22-0
189.934
195.632
199.431
203.230
281
Z-3-23-0
197.833
203.768
207.725
211.681
282
Z-3-24-0
388.703
400.364
408.138
415.912
283
Z-3-25-0
173.128
178.321
181.784
185.247
284
Z-3-26-0
195.668
201.538
205.452
209.365
285
Z-3-27-0
PERAWATAN LUKA
186.810
192.415
196.151
199.887
286
Z-3-28-0
IMAGING PAYUDARA
191.760
197.513
201.348
205.183
287
Z-3-29-0
IMAGING LAIN-LAIN
552.686
569.267
580.321
591.375
288
Z-3-30-0
FOTOTERAPI
93.273
96.071
97.937
99.802

JALAN LAHIR
- 71 2. RUMAH SAKIT KUSTA KELAS A

a. RawatInap
No
Kode
INA-CBG
A-4-10-i
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
SEPTIKEMIA RINGAN
2.736.833
2.818.938
2.873.675
2.928.411
A-4-10-ii
SEPTIKEMIA SEDANG
3.132.938
3.226.926
3.289.585
3.352.244
A-4-10-iii
SEPTIKEMIA BERAT
4.911.856
5.059.212
5.157.449
5.255.686
A-4-11-i
4.918.728
5.066.290
5.164.664
5.263.039
A-4-11-ii
7.598.866
7.826.832
7.978.809
8.130.787
A-4-11-iii
12.430.084
12.802.987
13.051.589
13.300.190
A-4-12-i
DEMAM RINGAN
1.929.531
1.987.417
2.026.008
2.064.598
A-4-12-ii
DEMAM SEDANG
2.767.495
2.850.520
2.905.870
2.961.219
A-4-12-iii
DEMAM BERAT
3.167.195
3.262.211
3.325.555
3.388.898
10
A-4-13-i
2.411.914
2.484.271
2.532.510
2.580.748
11
A-4-13-ii
2.894.297
2.981.126
3.039.012
3.096.897
12
A-4-13-iii
3.517.676
3.623.206
3.693.559
3.763.913
248.429
255.882
260.851
265.819
319.683
329.274
335.668
342.061
365.270
376.229
383.534
390.839

LAIN-LAIN RINGAN
LAIN-LAIN SEDANG
LAIN-LAIN BERAT
13
A-4-14-i
14
A-4-14-ii
15
A-4-14-iii
16
A-4-15-i
INFEKSI HIV RINGAN
2.894.297
2.981.126
3.039.012
3.096.897
17
A-4-15-ii
INFEKSI HIV SEDANG
4.341.445
4.471.688
4.558.517
4.645.346
18
A-4-15-iii
INFEKSI HIV BERAT
6.037.927
6.219.065
6.339.824
6.460.582
19
B-1-01-i
32.087.791
33.050.425
33.692.181
34.333.937
20
B-1-01-ii
35.401.413
36.463.455
37.171.483
37.879.512
21
B-1-01-iii
62.101.363
63.964.404
65.206.431
66.448.458
22
B-1-10-i
4.160.073
4.284.875
4.368.077
4.451.278
23
B-1-10-ii
10.601.870
10.919.927
11.131.964
11.344.001
24
B-1-10-iii
18.453.662
19.007.272
19.376.345
19.745.418
2.843.954
2.929.272
2.986.151
3.043.030
7.138.592
7.352.750
7.495.521
7.638.293
8.950.023
9.218.523
9.397.524
9.576.524
6.066.256
6.248.243
6.369.568
6.490.893
13.001.469
13.391.514
13.651.543
13.911.572
15.823.278
16.297.977
16.614.442
16.930.908
25
B-1-11-i
26
B-1-11-ii
27
B-1-11-iii
28
B-1-12-i
29
B-1-12-ii
30
B-1-12-iii

(RINGAN)
(SEDANG)
(BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT
- 72 No
Kode
INA-CBG
31
B-1-13-i
32
B-1-13-ii
33
B-1-13-iii
34
B-1-14-i
35
B-1-14-ii
36
B-1-14-iii
37
B-4-10-i
38
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.975.082
4.094.335
4.173.836
4.253.338
6.474.832
6.669.077
6.798.574
6.928.070
9.545.719
9.832.091
10.023.005
10.213.920
5.397.882
5.559.818
5.667.776
5.775.734
6.003.534
6.183.640
6.303.711
6.423.781
9.391.815
9.673.570
9.861.406
10.049.242
1.509.610
1.554.898
1.585.090
1.615.282
B-4-10-ii
2.411.914
2.484.271
2.532.510
2.580.748
39
B-4-10-iii
3.687.530
3.798.156
3.871.907
3.945.657
40
B-4-11-i
3.646.298
3.755.687
3.828.613
3.901.539
41
B-4-11-ii
5.543.284
5.709.582
5.820.448
5.931.313
42
B-4-11-iii
5.970.309
6.149.418
6.268.824
6.388.231
43
B-4-12-i
3.199.377
3.295.358
3.359.346
3.423.333
44
B-4-12-ii
4.535.929
4.672.007
4.762.725
4.853.444
45
B-4-12-iii
8.815.985
9.080.465
9.256.785
9.433.104
46
B-4-13-i
2.894.297
2.981.126
3.039.012
3.096.897
47
B-4-13-ii
4.516.709
4.652.210
4.742.544
4.832.878
48
B-4-13-iii
6.855.406
7.061.068
7.198.176
7.335.284
49
B-4-14-i
2.894.297
2.981.126
3.039.012
3.096.897
50
B-4-14-ii
3.376.680
3.477.980
3.545.513
3.613.047
51
B-4-14-iii
4.504.830
4.639.975
4.730.072
4.820.168
52
C-4-10-i
2.818.461
2.903.015
2.959.384
3.015.753
53
C-4-10-ii
5.475.974
5.640.253
5.749.772
5.859.292
54
C-4-10-iii
LEUKEMIA AKUT BERAT
9.165.273
9.440.231
9.623.537
9.806.842
55
C-4-11-i
2.894.297
2.981.126
3.039.012
3.096.897
56
C-4-11-ii
3.859.062
3.974.834
4.052.015
4.129.197
57
C-4-11-iii
6.560.858
6.757.683
6.888.901
7.020.118
58
C-4-12-i
RADIOTERAPI RINGAN
1.929.531
1.987.417
2.026.008
2.064.598
59
C-4-12-ii
RADIOTERAPI SEDANG
5.312.582
5.471.959
5.578.211
5.684.463
60
C-4-12-iii
RADIOTERAPI BERAT
10.785.606
11.109.174
11.324.886
11.540.598
61
C-4-13-i
KEMOTERAPI RINGAN
1.929.531
1.987.417
2.026.008
2.064.598
62
C-4-13-ii
KEMOTERAPI SEDANG
3.859.062
3.974.834
4.052.015
4.129.197
63
C-4-13-iii
KEMOTERAPI BERAT
5.049.298
5.200.776
5.301.762
5.402.748

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT

PANCREAS RINGAN
PANCREAS SEDANG
PANCREAS BERAT
(RINGAN)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT
- 73 No
Kode
INA-CBG
64
C-4-14-i
65
C-4-14-ii
66
C-4-14-iii
67
D-1-10-i
68
D-1-10-ii
69
D-1-10-iii
70
D-1-11-i
71
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.502.086
2.577.148
2.627.190
2.677.232
3.656.208
3.765.894
3.839.018
3.912.142
5.573.783
5.740.996
5.852.472
5.963.947
20.532.500
21.148.475
21.559.125
21.969.775
31.272.572
32.210.749
32.836.201
33.461.652
42.382.880
43.654.367
44.502.024
45.349.682
4.220.279
4.346.887
4.431.293
4.515.698
D-1-11-ii
11.007.262
11.337.480
11.557.625
11.777.770
72
D-1-11-iii
15.595.481
16.063.345
16.375.255
16.687.165
73
D-1-20-i
5.198.494
5.354.448
5.458.418
5.562.388
74
D-1-20-ii
11.696.611
12.047.509
12.281.441
12.515.373
75
D-1-20-iii
21.143.560
21.777.867
22.200.738
22.623.609
76
D-4-10-i
1.853.433
1.909.036
1.946.105
1.983.174
77
D-4-10-ii
3.742.430
3.854.703
3.929.552
4.004.400
78
D-4-10-iii
4.823.828
4.968.543
5.065.019
5.161.496
79
D-4-11-i
4.220.849
4.347.475
4.431.892
4.516.309
80
D-4-11-ii
7.543.794
7.770.107
7.920.983
8.071.859
81
D-4-11-iii
10.327.905
10.637.742
10.844.300
11.050.859
82
D-4-12-i
2.474.164
2.548.388
2.597.872
2.647.355
83
D-4-12-ii
3.431.908
3.534.865
3.603.503
3.672.142
84
D-4-12-iii
5.269.697
5.427.787
5.533.181
5.638.575
85
D-4-13-i
1.929.531
1.987.417
2.026.008
2.064.598
86
D-4-13-ii
2.894.297
2.981.126
3.039.012
3.096.897
87
D-4-13-iii
3.376.680
3.477.980
3.545.513
3.613.047
88
D-4-14-i
2.324.850
2.394.595
2.441.092
2.487.589
89
D-4-14-ii
5.427.955
5.590.794
5.699.353
5.807.912
90
D-4-14-iii
6.474.800
6.669.044
6.798.540
6.928.036
91
E-1-01-i
4.625.290
4.764.049
4.856.555
4.949.060
92
E-1-01-ii
6.058.690
6.240.451
6.361.625
6.482.798
93
E-1-01-iii
13.732.161
14.144.126
14.418.769
14.693.413
94
E-1-10-i
4.712.923
4.854.311
4.948.569
5.042.828
95
E-1-10-ii
5.720.382
5.891.994
6.006.401
6.120.809
96
E-1-10-iii
12.056.882
12.418.588
12.659.726
12.900.864

RINGAN
SEDANG
BERAT
TULANG RINGAN
TULANG SEDANG
TULANG BERAT


RINGAN
SEDANG
BERAT
- 74 No
Kode
INA-CBG
97
E-1-20-i
98
E-1-20-ii
99
E-1-20-iii
100
E-4-10-i
101
E-4-10-ii
102
E-4-10-iii
103
E-4-11-i
104
E-4-11-ii
105
E-4-11-iii
106
E-4-12-i
107
108
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.457.662
5.621.392
5.730.546
5.839.699
7.309.657
7.528.947
7.675.140
7.821.333
16.196.134
16.682.018
17.005.941
17.329.864
2.411.914
2.484.271
2.532.510
2.580.748
3.430.249
3.533.157
3.601.762
3.670.367
6.556.854
6.753.560
6.884.697
7.015.834
2.057.867
2.119.603
2.160.760
2.201.918
3.893.131
4.009.925
4.087.788
4.165.650
6.419.952
6.612.551
6.740.950
6.869.349
2.458.864
2.532.629
2.581.807
2.630.984
E-4-12-ii
4.271.509
4.399.655
4.485.085
4.570.515
E-4-12-iii
6.975.048
7.184.299
7.323.800
7.463.301
2.593.620
2.671.428
2.723.301
2.775.173
4.453.263
4.586.861
4.675.926
4.764.992
7.705.270
7.936.428
8.090.534
8.244.639

RINGAN
SEDANG
BERAT

RINGAN
SEDANG
BERAT
109
E-4-13-i
110
E-4-13-ii
111
E-4-13-iii
112
F-4-10-i
SCHIZOFRENIA RINGAN
3.171.191
3.266.326
3.329.750
3.393.174
113
F-4-10-ii
SCHIZOFRENIA SEDANG
3.521.709
3.627.361
3.697.795
3.768.229
114
F-4-10-iii
SCHIZOFRENIA BERAT
5.213.968
5.370.387
5.474.667
5.578.946
115
F-4-11-i
2.923.070
3.010.762
3.069.223
3.127.685
116
F-4-11-ii
3.405.654
3.507.823
3.575.936
3.644.050
117
F-4-11-iii
DEPRESI MAYOR BERAT
4.367.293
4.498.312
4.585.657
4.673.003
1.447.148
1.490.563
1.519.506
1.548.449
2.066.323
2.128.312
2.169.639
2.210.965
4.482.540
4.617.016
4.706.667
4.796.318

IMPULSE RINGAN
IMPULSE SEDANG
IMPULSE BERAT
118
F-4-12-i
119
F-4-12-ii
120
F-4-12-iii
121
F-4-13-i
2.362.284
2.433.153
2.480.399
2.527.644
122
F-4-13-ii
3.128.272
3.222.120
3.284.685
3.347.251
123
F-4-13-iii
4.033.507
4.154.512
4.235.182
4.315.852
124
F-4-14-i
DEPRESI RINGAN
1.653.599
1.703.207
1.736.279
1.769.351
125
F-4-14-ii
DEPRESI SEDANG
2.121.076
2.184.709
2.227.130
2.269.552
126
F-4-14-iii
DEPRESI BERAT
2.854.003
2.939.623
2.996.703
3.053.783
127
F-4-15-i
1.966.035
2.025.016
2.064.337
2.103.658
128
F-4-15-ii
2.894.297
2.981.126
3.039.012
3.096.897
129
F-4-15-iii
3.811.966
3.926.325
4.002.565
4.078.804
- 75 No
Kode
INA-CBG
130
F-4-16-i
131
F-4-16-ii
132
F-4-16-iii
133
F-4-17-i
134
F-4-17-ii
135
F-4-17-iii
136
F-4-18-i
137
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.234.455
4.361.489
4.446.178
4.530.867
4.922.448
5.070.122
5.168.571
5.267.020
6.570.647
6.767.766
6.899.179
7.030.592
977.686
1.007.016
1.026.570
1.046.124
2.865.503
2.951.468
3.008.779
3.066.089
3.057.281
3.149.000
3.210.145
3.271.291
3.670.283
3.780.392
3.853.797
3.927.203
F-4-18-ii
4.038.348
4.159.499
4.240.265
4.321.032
138
F-4-18-iii
6.225.466
6.412.230
6.536.739
6.661.248
139
F-4-19-i
2.814.761
2.899.204
2.955.499
3.011.794
140
F-4-19-ii
3.604.374
3.712.505
3.784.592
3.856.680
141
F-4-19-iii
4.487.493
4.622.118
4.711.868
4.801.618
142
G-1-01-i
8.948.725
9.217.187
9.396.162
9.575.136
143
G-1-01-ii
15.146.796
15.601.200
15.904.136
16.207.072
144
G-1-01-iii
29.322.505
30.202.181
30.788.631
31.375.081
145
G-1-10-i
4.465.865
4.599.841
4.689.159
4.778.476
146
G-1-10-ii
6.304.692
6.493.832
6.619.926
6.746.020
147
G-1-10-iii
7.472.406
7.696.578
7.846.027
7.995.475
148
G-1-11-i
5.151.509
5.306.054
5.409.084
5.512.115
149
G-1-11-ii
10.579.012
10.896.382
11.107.962
11.319.543
150
G-1-11-iii
22.151.489
22.816.034
23.259.063
23.702.093
151
G-1-12-i
4.006.356
4.126.547
4.206.674
4.286.801
152
G-1-12-ii
9.172.154
9.447.318
9.630.761
9.814.204
153
G-1-12-iii
16.177.668
16.662.998
16.986.551
17.310.104
154
G-1-13-i
1.056.601
1.088.299
1.109.431
1.130.563
155
G-1-13-ii
2.837.914
2.923.052
2.979.810
3.036.568
156
G-1-13-iii
6.403.530
6.595.636
6.723.706
6.851.777
5.048.350
5.199.800
5.300.767
5.401.734
6.820.486
7.025.100
7.161.510
7.297.920
16.699.157
17.200.132
17.534.115
17.868.098

RINGAN
SEDANG
BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

RINGAN
SEDANG
BERAT
157
G-1-20-i
158
G-1-20-ii
159
G-1-20-iii
160
G-1-30-i
6.438.715
6.631.877
6.760.651
6.889.426
161
G-1-30-ii
16.805.665
17.309.835
17.645.948
17.982.061
162
G-1-30-iii
21.634.084
22.283.106
22.715.788
23.148.470
- 76 No
Kode
INA-CBG
163
G-4-10-i
164
G-4-10-ii
165
G-4-10-iii
166
G-4-11-i
167
G-4-11-ii
168
G-4-11-iii
169
G-4-12-i
170
G-4-12-ii
171
G-4-12-iii
172
G-4-13-i
173
G-4-13-ii
174
G-4-13-iii
175
G-4-14-i
176
G-4-14-ii
177
G-4-14-iii
178
G-4-15-i
179
G-4-15-ii
180
G-4-15-iii
181
G-4-16-i
182
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.894.297
2.981.126
3.039.012
3.096.897
3.376.680
3.477.980
3.545.513
3.613.047
5.158.630
5.313.389
5.416.561
5.519.734
4.775.382
4.918.644
5.014.151
5.109.659
5.539.443
5.705.627
5.816.415
5.927.204
8.118.150
8.361.694
8.524.057
8.686.420
3.571.566
3.678.713
3.750.144
3.821.575
4.500.173
4.635.178
4.725.181
4.815.185
6.535.965
6.732.044
6.862.763
6.993.483
1.987.195
2.046.811
2.086.555
2.126.299
3.376.680
3.477.980
3.545.513
3.613.047
3.991.715
4.111.466
4.191.300
4.271.135
3.634.284
3.743.312
3.815.998
3.888.684
5.979.623
6.159.012
6.278.604
6.398.197
7.486.624
7.711.223
7.860.956
8.010.688
3.719.795
3.831.389
3.905.785
3.980.181
4.494.815
4.629.659
4.719.555
4.809.452
5.554.365
5.720.996
5.832.083
5.943.170
2.411.914
2.484.271
2.532.510
2.580.748
G-4-16-ii
3.607.039
3.715.250
3.787.391
3.859.532
183
G-4-16-iii
6.546.132
6.742.516
6.873.438
7.004.361
184
G-4-17-i
3.446.846
3.550.251
3.619.188
3.688.125
185
G-4-17-ii
4.277.687
4.406.018
4.491.571
4.577.125
186
G-4-17-iii
7.169.439
7.384.522
7.527.911
7.671.299
187
G-4-18-i
2.894.297
2.981.126
3.039.012
3.096.897
188
G-4-18-ii
4.149.921
4.274.418
4.357.417
4.440.415
189
G-4-18-iii
4.396.418
4.528.311
4.616.239
4.704.167
190
G-4-19-i
2.411.914
2.484.271
2.532.510
2.580.748
191
G-4-19-ii
4.888.068
5.034.710
5.132.471
5.230.233
192
G-4-19-iii
7.291.446
7.510.189
7.656.018
7.801.847

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
DEGENERATIF RINGAN
DEGENERATIF SEDANG
DEGENERATIF BERAT
RINGAN
SEDANG
BERAT
TRAUMATIK RINGAN
TRAUMATIK SEDANG
TRAUMATIK BERAT
DENGAN INFARK BERAT
TANPA INFARK RINGAN
TANPA INFARK SEDANG
TANPA INFARK BERAT

PERIFER RINGAN
PERIFER SEDANG
PERIFER BERAT
PERSARAFAN RINGAN
PERSARAFAN SEDANG
PERSARAFAN BERAT
SEDANG
- 77 No
Kode
INA-CBG
193
G-4-20-i
194
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.688.340
1.738.990
1.772.757
1.806.524
G-4-20-ii
2.397.444
2.469.368
2.517.317
2.565.265
195
G-4-20-iii
4.088.204
4.210.850
4.292.614
4.374.378
196
G-4-21-i
1.956.400
2.015.092
2.054.220
2.093.348
197
G-4-21-ii
4.051.899
4.173.456
4.254.494
4.335.532
198
G-4-21-iii
4.773.615
4.916.824
5.012.296
5.107.768
199
G-4-22-i
1.929.531
1.987.417
2.026.008
2.064.598
200
G-4-22-ii
2.411.914
2.484.271
2.532.510
2.580.748
201
G-4-22-iii
2.767.096
2.850.109
2.905.451
2.960.793
202
G-4-23-i
1.929.531
1.987.417
2.026.008
2.064.598
203
G-4-23-ii
2.411.914
2.484.271
2.532.510
2.580.748
204
G-4-23-iii
3.447.660
3.551.090
3.620.043
3.688.996
205
G-4-24-i
1.929.531
1.987.417
2.026.008
2.064.598
206
G-4-24-ii
2.411.914
2.484.271
2.532.510
2.580.748
207
G-4-24-iii
TRAUMA KEPALA BERAT
5.068.376
5.220.427
5.321.795
5.423.162
208
G-4-25-i
GEGAR OTAK RINGAN
1.833.431
1.888.434
1.925.103
1.961.772
209
G-4-25-ii
GEGAR OTAK SEDANG
2.308.330
2.377.580
2.423.747
2.469.913
210
G-4-25-iii
GEGAR OTAK BERAT
3.011.733
3.102.085
3.162.319
3.222.554
211
G-4-26-i
2.894.297
2.981.126
3.039.012
3.096.897
212
G-4-26-ii
3.376.680
3.477.980
3.545.513
3.613.047
213
G-4-26-iii
6.445.609
6.638.977
6.767.889
6.896.801
214
H-1-20-i
2.773.492
2.856.697
2.912.167
2.967.636
215
H-1-20-ii
5.057.777
5.209.510
5.310.665
5.411.821
216
H-1-20-iii
6.878.260
7.084.608
7.222.173
7.359.738
217
H-1-30-i
2.715.513
2.796.978
2.851.288
2.905.599
218
H-1-30-ii
3.095.685
3.188.555
3.250.469
3.312.382
219
H-1-30-iii
5.165.038
5.319.989
5.423.290
5.526.590
220
H-4-10-i
2.894.297
2.981.126
3.039.012
3.096.897
221
H-4-10-ii
4.823.828
4.968.543
5.065.019
5.161.496
222
H-4-10-iii
7.864.264
8.100.192
8.257.477
8.414.763
223
H-4-11-i
1.970.698
2.029.819
2.069.233
2.108.647
224
H-4-11-ii
2.201.962
2.268.020
2.312.060
2.356.099
225
H-4-11-iii
3.148.599
3.243.057
3.306.029
3.369.001
226
H-4-12-i
2.734.265
2.816.293
2.870.978
2.925.663

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)

RINGAN
SEDANG
- 78 No
Kode
INA-CBG
227
H-4-12-ii
228
H-4-12-iii
229
I-1-01-i
230
I-1-01-ii
231
I-1-01-iii
232
I-1-02-i
233
I-1-02-ii
234
I-1-02-iii
235
I-1-03-i
236
I-1-03-ii
237
I-1-03-iii
238
I-1-04-i
239
I-1-04-ii
240
I-1-04-iii
241
I-1-05-i
242
I-1-05-ii
243
I-1-05-iii
244
I-1-06-i
245
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.703.741
3.814.853
3.888.928
3.963.002
6.179.438
6.364.822
6.488.410
6.611.999
41.627.323
42.876.143
43.708.689
44.541.235
42.543.341
43.819.641
44.670.508
45.521.375
67.153.848
69.168.463
70.511.540
71.854.617
23.094.599
23.787.437
24.249.329
24.711.221
29.792.033
30.685.794
31.281.634
31.877.475
36.720.412
37.822.025
38.556.433
39.290.841
14.222.476
14.649.150
14.933.599
15.218.049
19.494.351
20.079.182
20.469.069
20.858.956
28.591.715
29.449.467
30.021.301
30.593.135
17.351.004
17.871.534
18.218.554
18.565.574
22.287.672
22.956.302
23.402.056
23.847.809
47.512.689
48.938.070
49.888.324
50.838.578
30.566.381
31.483.372
32.094.700
32.706.028
36.679.657
37.780.047
38.513.640
39.247.233
50.470.977
51.985.106
52.994.526
54.003.945
14.408.314
14.840.563
15.128.730
15.416.896
I-1-06-ii
21.745.566
22.397.933
22.832.844
23.267.756
246
I-1-06-iii
27.994.318
28.834.147
29.394.034
29.953.920
247
I-1-07-i
18.948.024
19.516.465
19.895.425
20.274.386
248
I-1-07-ii
23.376.237
24.077.524
24.545.049
25.012.573
249
I-1-07-iii
25.503.322
26.268.422
26.778.488
27.288.555
250
I-1-11-i
3.604.376
3.712.507
3.784.595
3.856.683
251
I-1-11-ii
4.007.706
4.127.937
4.208.091
4.288.245
252
I-1-11-iii
5.333.035
5.493.026
5.599.687
5.706.347
253
I-1-12-i
11.046.799
11.378.203
11.599.139
11.820.075
254
I-1-12-ii
15.327.949
15.787.788
16.094.347
16.400.906
255
I-1-12-iii
21.378.871
22.020.237
22.447.815
22.875.392

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
KATETERISASI RINGAN
KATETERISASI SEDANG
KATETERISASI BERAT
RINGAN
SEDANG
BERAT

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
- 79 No
Kode
INA-CBG
256
I-1-13-i
257
I-1-13-ii
258
I-1-13-iii
259
I-1-14-i
260
I-1-14-ii
261
I-1-14-iii
262
I-1-15-i
263
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
6.498.117
6.693.061
6.823.023
6.952.985
7.560.161
7.786.966
7.938.169
8.089.372
13.781.668
14.195.118
14.470.751
14.746.385
23.773.852
24.487.067
24.962.544
25.438.021
29.547.502
30.433.927
31.024.877
31.615.827
38.717.416
39.878.938
40.653.287
41.427.635
4.658.535
4.798.291
4.891.462
4.984.632
I-1-15-ii
13.646.046
14.055.427
14.328.348
14.601.269
264
I-1-15-iii
70.633.971
72.752.990
74.165.669
75.578.349
265
I-1-16-i
10.188.794
10.494.457
10.698.233
10.902.009
266
I-1-16-ii
26.490.863
27.285.589
27.815.407
28.345.224
267
I-1-16-iii
30.556.561
31.473.258
32.084.389
32.695.520
268
I-1-17-i
3.267.628
3.365.657
3.431.009
3.496.362
269
I-1-17-ii
6.768.442
6.971.496
7.106.864
7.242.233
270
I-1-17-iii
39.239.311
40.416.491
41.201.277
41.986.063
271
I-1-20-i
3.898.870
4.015.836
4.093.814
4.171.791
272
I-1-20-ii
7.017.966
7.228.505
7.368.864
7.509.224
273
I-1-20-iii
9.357.289
9.638.007
9.825.153
10.012.299
274
I-1-30-i
11.559.239
11.906.017
12.137.201
12.368.386
275
I-1-30-ii
24.045.553
24.766.920
25.247.831
25.728.742
276
I-1-30-iii
37.261.874
38.379.730
39.124.968
39.870.205
277
I-1-40-i
15.544.571
16.010.908
16.321.800
16.632.691
278
I-1-40-ii
21.588.070
22.235.712
22.667.474
23.099.235
279
I-1-40-iii
27.050.842
27.862.367
28.403.384
28.944.401
280
I-4-10-i
4.520.813
4.656.437
4.746.854
4.837.270
281
I-4-10-ii
7.138.445
7.352.598
7.495.367
7.638.136
282
I-4-10-iii
10.297.829
10.606.764
10.812.721
11.018.677
283
I-4-11-i
5.360.502
5.521.317
5.628.527
5.735.737
284
I-4-11-ii
6.633.642
6.832.651
6.965.324
7.097.997

KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

DARAH VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
- 80 No
Kode
INA-CBG
285
I-4-11-iii
286
I-4-12-i
287
288
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
11.739.972
12.092.171
12.326.970
12.561.770
4.695.243
4.836.100
4.930.005
5.023.909
I-4-12-ii
6.700.098
6.901.101
7.035.103
7.169.105
I-4-12-iii
8.128.161
8.372.006
8.534.569
8.697.132
4.217.618
4.344.147
4.428.499
4.512.852
6.127.339
6.311.159
6.433.706
6.556.253
12.541.952
12.918.211
13.169.050
13.419.889

VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
289
I-4-13-i
290
I-4-13-ii
291
I-4-13-iii
292
I-4-14-i
2.622.969
2.701.658
2.754.118
2.806.577
293
I-4-14-ii
3.069.262
3.161.340
3.222.725
3.284.110
294
I-4-14-iii
4.756.335
4.899.025
4.994.151
5.089.278
3.859.062
3.974.834
4.052.015
4.129.197
5.524.439
5.690.172
5.800.661
5.911.149
6.296.531
6.485.427
6.611.358
6.737.288

295
I-4-15-i
296
I-4-15-ii
297
I-4-15-iii
298
I-4-16-i
2.894.297
2.981.126
3.039.012
3.096.897
299
I-4-16-ii
4.690.658
4.831.378
4.925.191
5.019.004
300
I-4-16-iii
5.909.396
6.086.678
6.204.866
6.323.054
301
I-4-17-i
HIPERTENSI RINGAN
2.590.336
2.668.046
2.719.852
2.771.659
302
I-4-17-ii
HIPERTENSI SEDANG
3.668.173
3.778.218
3.851.582
3.924.945
303
I-4-17-iii
HIPERTENSI BERAT
4.462.508
4.596.383
4.685.633
4.774.883
3.814.820
3.929.265
4.005.561
4.081.858
5.844.049
6.019.371
6.136.252
6.253.133
7.878.715
8.115.077
8.272.651
8.430.225
2.985.597
3.075.165
3.134.877
3.194.589
4.890.314
5.037.024
5.134.830
5.232.636
5.829.210
6.004.086
6.120.671
6.237.255

RINGAN
SEDANG
KONGENITAL BERAT
RINGAN
SEDANG
BERAT
304
I-4-18-i
305
I-4-18-ii
306
I-4-18-iii
307
I-4-19-i
308
I-4-19-ii
309
I-4-19-iii
310
I-4-20-i
3.623.445
3.732.148
3.804.617
3.877.086
311
I-4-20-ii
4.174.479
4.299.713
4.383.203
4.466.693
312
I-4-20-iii
5.540.228
5.706.435
5.817.240
5.928.044
313
I-4-21-i
4.818.595
4.963.153
5.059.525
5.155.897
314
I-4-21-ii
6.010.885
6.191.211
6.311.429
6.431.647
315
I-4-21-iii
8.200.121
8.446.125
8.610.127
8.774.130
316
I-4-22-i
3.135.488
3.229.553
3.292.263
3.354.972
317
I-4-22-ii
3.613.021
3.721.411
3.793.672
3.865.932
- 81 No
Kode
INA-CBG
318
I-4-22-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.271.299
5.429.438
5.534.864
5.640.290
2.375.309
2.446.568
2.494.075
2.541.581
2.916.332
3.003.822
3.062.149
3.120.475
5.698.247
5.869.195
5.983.160
6.097.125
2.833.058
2.918.050
2.974.711
3.031.372
7.073.362
7.285.562
7.427.030
7.568.497
8.942.988
9.211.278
9.390.137
9.568.997
23.266.717
23.964.719
24.430.053
24.895.388
25.342.657
26.102.936
26.609.789
27.116.642
41.660.116
42.909.919
43.743.121
44.576.324
11.667.726
12.017.758
12.251.113
12.484.467
12.499.244
12.874.221
13.124.206
13.374.191
18.470.321
19.024.430
19.393.837
19.763.243
4.552.916
4.689.503
4.780.561
4.871.620
10.996.946
11.326.854
11.546.793
11.766.732
19.471.444
20.055.587
20.445.016
20.834.445
3.935.176
4.053.231
4.131.935
4.210.638
5.723.403
5.895.105
6.009.573
6.124.041
8.606.230
8.864.417
9.036.541
9.208.666
2.653.706
2.733.318
2.786.392
2.839.466
12.996.234
13.386.121
13.646.046
13.905.971
39.196.071
40.371.954
41.155.875
41.939.796
319
I-4-23-i
320
I-4-23-ii
321
I-4-23-iii
322
I-4-24-i
323
I-4-24-ii
324
I-4-24-iii
325
J-1-01-i
326
J-1-01-ii
327
J-1-01-iii
328
J-1-02-i
329
J-1-02-ii
330
J-1-02-iii
331
J-1-10-i
332
J-1-10-ii
333
J-1-10-iii
334
J-1-20-i
335
J-1-20-ii
336
J-1-20-iii
337
J-1-30-i
338
J-1-30-ii
339
J-1-30-iii
340
J-4-10-i
3.062.731
3.154.613
3.215.868
3.277.123
341
J-4-10-ii
4.379.338
4.510.718
4.598.305
4.685.892
342
J-4-10-iii
6.625.285
6.824.043
6.956.549
7.089.055
343
J-4-11-i
1.932.194
1.990.160
2.028.804
2.067.447
344
J-4-11-ii
2.689.570
2.770.257
2.824.048
2.877.840
345
J-4-11-iii
3.854.222
3.969.849
4.046.933
4.124.018
346
J-4-12-i
EMBOLI PARU RINGAN
2.954.826
3.043.471
3.102.568
3.161.664
347
J-4-12-ii
EMBOLI PARU SEDANG
3.826.399
3.941.191
4.017.719
4.094.247
348
J-4-12-iii
EMBOLI PARU BERAT
5.109.769
5.263.062
5.365.258
5.467.453
- 82 No
Kode
INA-CBG
349
J-4-13-i
350
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.551.554
4.688.101
4.779.132
4.870.163
J-4-13-ii
6.690.785
6.891.509
7.025.324
7.159.140
351
J-4-13-iii
10.878.215
11.204.562
11.422.126
11.639.690
352
J-4-14-i
TUMOR PARU RINGAN
3.101.741
3.194.793
3.256.828
3.318.862
353
J-4-14-ii
TUMOR PARU SEDANG
5.195.840
5.351.715
5.455.632
5.559.549
354
J-4-14-iii
TUMOR PARU BERAT
6.177.590
6.362.917
6.486.469
6.610.021
2.894.297
2.981.126
3.039.012
3.096.897
5.237.654
5.394.783
5.499.537
5.604.290
6.544.344
6.740.674
6.871.561
7.002.448
2.411.914
2.484.271
2.532.510
2.580.748
3.376.680
3.477.980
3.545.513
3.613.047
6.091.175
6.273.910
6.395.733
6.517.557

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
355
J-4-15-i
356
J-4-15-ii
357
J-4-15-iii
358
J-4-16-i
359
J-4-16-ii
360
J-4-16-iii
361
J-4-17-i
3.012.107
3.102.471
3.162.713
3.222.955
362
J-4-17-ii
4.069.875
4.191.971
4.273.369
4.354.766
363
J-4-17-iii
5.320.998
5.480.628
5.587.048
5.693.468
364
J-4-18-i
2.710.044
2.791.346
2.845.547
2.899.747
365
J-4-18-ii
3.773.467
3.886.671
3.962.140
4.037.610
366
J-4-18-iii
3.913.919
4.031.337
4.109.615
4.187.894
367
J-4-19-i
3.376.680
3.477.980
3.545.513
3.613.047
368
J-4-19-ii
3.859.062
3.974.834
4.052.015
4.129.197
369
J-4-19-iii
6.045.674
6.227.044
6.347.957
6.468.871
370
J-4-20-i
3.376.680
3.477.980
3.545.513
3.613.047
371
J-4-20-ii
4.118.925
4.242.493
4.324.871
4.407.250
372
J-4-20-iii
9.307.285
9.586.504
9.772.650
9.958.795
1.929.531
1.987.417
2.026.008
2.064.598
4.760.506
4.903.321
4.998.531
5.093.741
6.790.038
6.993.739
7.129.540
7.265.341
5.198.494
5.354.448
5.458.418
5.562.388
7.254.839
7.472.485
7.617.581
7.762.678
8.496.666
8.751.566
8.921.499
9.091.433

USUS BESAR (RINGAN)
USUS BESAR (SEDANG)
USUS BESAR (BERAT)
373
J-4-21-i
374
J-4-21-ii
375
J-4-21-iii
376
K-1-10-i
377
K-1-10-ii
378
K-1-10-iii
379
K-1-11-i
4.469.905
4.604.002
4.693.400
4.782.798
380
K-1-11-ii
5.868.446
6.044.499
6.161.868
6.279.237
381
K-1-11-iii
14.892.960
15.339.749
15.637.608
15.935.468
- 83 No
Kode
INA-CBG
382
K-1-12-i
383
K-1-12-ii
384
K-1-12-iii
385
K-1-13-i
386
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.404.467
2.476.601
2.524.690
2.572.779
3.133.764
3.227.777
3.290.452
3.353.127
6.233.715
6.420.727
6.545.401
6.670.076
2.731.145
2.813.079
2.867.702
2.922.325
K-1-13-ii
4.770.525
4.913.641
5.009.052
5.104.462
387
K-1-13-iii
5.101.905
5.254.962
5.357.000
5.459.038
388
K-1-14-i
4.413.691
4.546.102
4.634.376
4.722.650
389
K-1-14-ii
5.184.381
5.339.912
5.443.600
5.547.287
390
K-1-14-iii
12.765.448
13.148.412
13.403.721
13.659.030
391
K-1-20-i
8.563.856
8.820.772
8.992.049
9.163.326
392
K-1-20-ii
11.952.885
12.311.471
12.550.529
12.789.587
393
K-1-20-iii
25.531.926
26.297.884
26.808.523
27.319.161
394
K-1-30-i
5.637.156
5.806.271
5.919.014
6.031.757
395
K-1-30-ii
10.396.987
10.708.897
10.916.837
11.124.776
396
K-1-30-iii
16.191.974
16.677.733
17.001.573
17.325.412
397
K-1-40-i
5.663.204
5.833.100
5.946.364
6.059.628
398
K-1-40-ii
6.231.794
6.418.747
6.543.383
6.668.019
399
K-1-40-iii
10.334.830
10.644.874
10.851.571
11.058.268
400
K-1-50-i
4.319.658
4.449.248
4.535.641
4.622.034
401
K-1-50-ii
5.594.161
5.761.986
5.873.869
5.985.753
402
K-1-50-iii
PROSEDUR ANAL BERAT
7.942.221
8.180.488
8.339.332
8.498.177
403
K-4-10-i
3.271.830
3.369.985
3.435.422
3.500.859
404
K-4-10-ii
3.914.937
4.032.385
4.110.684
4.188.983
405
K-4-10-iii
16.211.704
16.698.056
17.022.290
17.346.524
406
K-4-11-i
1.929.531
1.987.417
2.026.008
2.064.598
407
K-4-11-ii
2.894.297
2.981.126
3.039.012
3.096.897
408
K-4-11-iii
5.259.980
5.417.779
5.522.979
5.628.179
409
K-4-12-i
1.929.531
1.987.417
2.026.008
2.064.598
410
K-4-12-ii
2.882.690
2.969.170
3.026.824
3.084.478
411
K-4-12-iii
6.918.250
7.125.797
7.264.162
7.402.527
412
K-4-13-i
2.894.297
2.981.126
3.039.012
3.096.897
413
K-4-13-ii
3.748.827
3.861.292
3.936.268
4.011.245


RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)

(RINGAN)
(SEDANG)
- 84 No
Kode
INA-CBG
414
K-4-13-iii
415
K-4-14-i
416
K-4-14-ii
417
K-4-14-iii
418
K-4-15-i
419
K-4-15-ii
420
K-4-15-iii
421
K-4-16-i
422
423
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
6.131.440
6.315.383
6.438.012
6.560.641
2.411.914
2.484.271
2.532.510
2.580.748
3.264.274
3.362.202
3.427.487
3.492.773
4.937.525
5.085.651
5.184.402
5.283.152
2.411.914
2.484.271
2.532.510
2.580.748
4.535.056
4.671.108
4.761.809
4.852.510
6.452.568
6.646.146
6.775.197
6.904.248
2.411.914
2.484.271
2.532.510
2.580.748
K-4-16-ii
2.894.297
2.981.126
3.039.012
3.096.897
K-4-16-iii
3.532.865
3.638.851
3.709.508
3.780.166
1.929.531
1.987.417
2.026.008
2.064.598
2.815.222
2.899.679
2.955.983
3.012.288
3.746.773
3.859.176
3.934.112
4.009.047
1.929.531
1.987.417
2.026.008
2.064.598
2.995.433
3.085.296
3.145.204
3.205.113
3.543.582
3.649.889
3.720.761
3.791.633
19.745.377
20.337.739
20.732.646
21.127.554
20.540.636
21.156.855
21.567.667
21.978.480
31.470.625
32.414.744
33.044.156
33.673.569
1.153.085
1.187.678
1.210.740
1.233.801
1.670.248
1.720.355
1.753.760
1.787.165
1.761.590
1.814.438
1.849.670
1.884.902
465.582
479.550
488.861
498.173
1.047.886
1.079.323
1.100.280
1.121.238
1.775.890
1.829.167
1.864.685
1.900.202

RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
424
K-4-17-i
425
K-4-17-ii
426
K-4-17-iii
427
K-4-18-i
428
K-4-18-ii
429
K-4-18-iii
430
L-1-20-i
431
L-1-20-ii
432
L-1-20-iii
433
L-1-30-i
434
L-1-30-ii
435
L-1-30-iii
436
L-1-40-i
437
L-1-40-ii
438
L-1-40-iii
439
L-1-50-i
6.498.117
6.693.061
6.823.023
6.952.985
440
L-1-50-ii
11.696.611
12.047.509
12.281.441
12.515.373
441
L-1-50-iii
14.142.857
14.567.143
14.850.000
15.132.857
442
L-4-10-i
372.644
383.823
391.276
398.729
443
L-4-10-ii
434.751
447.794
456.489
465.184
444
L-4-10-iii
879.465
905.849
923.438
941.028
445
L-4-11-i
2.737.478
2.819.602
2.874.351
2.929.101
- 85 No
Kode
INA-CBG
446
L-4-11-ii
447
L-4-11-iii
448
L-4-12-i
449
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.750.296
3.862.805
3.937.811
4.012.817
10.170.335
10.475.445
10.678.852
10.882.258
372.644
383.823
391.276
398.729
L-4-12-ii
546.755
563.158
574.093
585.028
450
L-4-12-iii
916.844
944.349
962.686
981.023
451
L-4-13-i
1.816.663
1.871.163
1.907.496
1.943.829
452
L-4-13-ii
2.094.719
2.157.561
2.199.455
2.241.350
453
L-4-13-iii
3.142.242
3.236.509
3.299.354
3.362.199
454
L-4-14-i
248.429
255.882
260.851
265.819
455
L-4-14-ii
372.644
383.823
391.276
398.729
456
L-4-14-iii
582.636
600.115
611.768
623.420
457
M-1-01-i
1.211.190
1.247.526
1.271.750
1.295.973
458
M-1-01-ii
1.351.884
1.392.441
1.419.478
1.446.516
459
M-1-01-iii
1.899.031
1.956.002
1.993.982
2.031.963
460
M-1-02-i
773.785
796.999
812.474
827.950
461
M-1-02-ii
1.270.408
1.308.520
1.333.928
1.359.336
462
M-1-02-iii
2.300.650
2.369.670
2.415.683
2.461.696
2.079.052
2.141.424
2.183.005
2.224.586
2.497.238
2.572.156
2.622.100
2.672.045
2.593.585
2.671.392
2.723.264
2.775.135
510.443
525.756
535.965
546.174
654.382
674.014
687.101
700.189
818.836
843.401
859.778
876.155
795.172
819.027
834.930
850.834
919.006
946.576
964.956
983.336
1.565.317
1.612.276
1.643.583
1.674.889
973.098
1.002.291
1.021.753
1.041.215
1.303.647
1.342.757
1.368.830
1.394.903
2.655.654
2.735.323
2.788.436
2.841.549
548.582
565.040
576.011
586.983
2.038.517
2.099.673
2.140.443
2.181.213
2.542.720
2.619.001
2.669.856
2.720.710
463
M-1-03-i
464
M-1-03-ii
465
M-1-03-iii
466
M-1-04-i
467
M-1-04-ii
468
M-1-04-iii
469
M-1-05-i
470
M-1-05-ii
471
M-1-05-iii
472
M-1-07-i
473
M-1-07-ii
474
M-1-07-iii
475
M-1-10-i
476
M-1-10-ii
477
M-1-10-iii


TULANG WAJAH RINGAN
TULANG WAJAH SEDANG
TULANG WAJAH BERAT
- 86 No
Kode
INA-CBG
478
M-1-20-i
479
M-1-20-ii
480
M-1-20-iii
481
M-1-30-i
482
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
542.689
558.970
569.824
580.678
773.987
797.207
812.687
828.166
1.505.732
1.550.904
1.581.019
1.611.134
324.609
334.348
340.840
347.332
M-1-30-ii
670.726
690.847
704.262
717.676
483
M-1-30-iii
PROSEDUR KAKI BERAT
1.000.581
1.030.599
1.050.610
1.070.622
484
M-1-40-i
363.618
374.527
381.799
389.072
485
M-1-40-ii
669.312
689.392
702.778
716.164
486
M-1-40-iii
1.171.296
1.206.435
1.229.861
1.253.287
487
M-1-50-i
434.385
447.416
456.104
464.792
488
M-1-50-ii
874.427
900.660
918.148
935.637
489
M-1-50-iii
1.338.624
1.378.783
1.405.555
1.432.328
327.824
337.658
344.215
350.771
656.305
675.994
689.120
702.246
1.142.203
1.176.469
1.199.313
1.222.157
439.152
452.326
461.109
469.892
896.087
922.970
940.891
958.813
1.444.600
1.487.938
1.516.830
1.545.722

SENDI MAYOR RINGAN
SENDI MAYOR SEDANG
SENDI MAYOR BERAT

RINGAN
SEDANG
BERAT

SELAIN KAKI (BERAT)
490
M-1-60-i
491
M-1-60-ii
492
M-1-60-iii
493
M-1-70-i
494
M-1-70-ii
495
M-1-70-iii
496
M-1-80-i
353.837
364.453
371.529
378.606
497
M-1-80-ii
534.930
550.978
561.676
572.375
498
M-1-80-iii
1.231.547
1.268.493
1.293.124
1.317.755
499
M-4-10-i
248.429
255.882
260.851
265.819
500
M-4-10-ii
372.644
383.823
391.276
398.729
501
M-4-10-iii
FRAKTUR FEMUR BERAT
726.015
747.796
762.316
776.836
502
M-4-11-i
310.537
319.853
326.064
332.274
503
M-4-11-ii
680.378
700.789
714.397
728.004
504
M-4-11-iii
1.207.655
1.243.884
1.268.038
1.292.191
505
M-4-12-i
248.429
255.882
260.851
265.819
506
M-4-12-ii
452.017
465.578
474.618
483.658
507
M-4-12-iii
816.577
841.075
857.406
873.738
508
M-4-13-i
413.689
426.099
434.373
442.647

PANGGUL RINGAN
PANGGUL SEDANG
PANGGUL BERAT
PELVIS RINGAN
PELVIS SEDANG
PELVIS BERAT
- 87 No
Kode
INA-CBG
509
M-4-13-ii
510
M-4-13-iii
511
M-4-14-i
512
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
621.073
639.706
652.127
664.549
1.230.621
1.267.539
1.292.152
1.316.764
471.006
485.136
494.556
503.976
M-4-14-ii
581.856
599.312
610.949
622.586
513
M-4-14-iii
OSTEOMIELITIS BERAT
871.558
897.705
915.136
932.567
514
M-4-15-i
279.616
288.004
293.596
299.189
515
M-4-15-ii
372.844
384.030
391.487
398.944
516
M-4-15-iii
1.055.825
1.087.500
1.108.616
1.129.733
517
M-4-16-i
310.537
319.853
326.064
332.274
518
M-4-16-ii
496.859
511.765
521.702
531.639
519
M-4-16-iii
833.356
858.357
875.024
891.691
310.537
319.853
326.064
332.274
434.751
447.794
456.489
465.184
607.153
625.368
637.511
649.654
328.334
338.185
344.751
351.318
496.859
511.765
521.702
531.639
556.836
573.541
584.678
595.815
244.121
251.445
256.327
261.210
411.178
423.513
431.737
439.961
803.061
827.153
843.214
859.276
248.429
255.882
260.851
265.819
372.644
383.823
391.276
398.729
412.977
425.367
433.626
441.886
248.429
255.882
260.851
265.819
310.537
319.853
326.064
332.274
712.975
734.364
748.623
762.883

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
RINGAN
SEDANG
BERAT
ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
520
M-4-17-i
521
M-4-17-ii
522
M-4-17-iii
523
M-4-18-i
524
M-4-18-ii
525
M-4-18-iii
526
M-4-19-i
527
M-4-19-ii
528
M-4-19-iii
529
M-4-20-i
530
M-4-20-ii
531
M-4-20-iii
532
M-4-21-i
533
M-4-21-ii
534
M-4-21-iii
535
N-1-01-i
5.220.789
5.377.413
5.481.829
5.586.245
536
N-1-01-ii
7.061.000
7.272.830
7.414.050
7.555.270
537
N-1-01-iii
14.971.420
15.420.563
15.719.991
16.019.419
7.202.482
7.418.556
7.562.606
7.706.656
9.741.194
10.033.430
10.228.254
10.423.078
538
N-1-11-i
539
N-1-11-ii

RINGAN
SEDANG
- 88 No
Kode
INA-CBG
Deskripsi (INA-CBG)
540
N-1-11-iii

Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
20.654.230
21.273.857
21.686.941
22.100.026
3.898.870
4.015.836
4.093.814
4.171.791
9.070.446
9.342.559
9.523.968
9.705.377
16.531.452
17.027.396
17.358.025
17.688.654
541
N-1-12-i
542
N-1-12-ii
543
N-1-12-iii
544
N-1-20-i
5.278.762
5.437.125
5.542.700
5.648.276
545
N-1-20-ii
10.465.909
10.779.886
10.989.205
11.198.523
546
N-1-20-iii
11.972.051
12.331.213
12.570.654
12.810.095
6.280.020
6.468.420
6.594.020
6.719.621
9.543.273
9.829.571
10.020.437
10.211.302
10.985.881
11.315.457
11.535.175
11.754.892
5.658.912
5.828.680
5.941.858
6.055.036
7.670.857
7.900.983
8.054.400
8.207.817
8.921.429
9.189.072
9.367.500
9.545.929
2.411.914
2.484.271
2.532.510
2.580.748
3.229.620
3.326.509
3.391.101
3.455.694
7.069.057
7.281.129
7.422.510
7.563.891

URIN BAWAH RINGAN
URIN BAWAH SEDANG
URIN BAWAH BERAT
RINGAN
SEDANG
BERAT
GINJAL RINGAN
GINJAL SEDANG
GINJAL BERAT
547
N-1-30-i
548
N-1-30-ii
549
N-1-30-iii
550
N-1-40-i
551
N-1-40-ii
552
N-1-40-iii
553
N-4-10-i
554
N-4-10-ii
555
N-4-10-iii
556
N-4-11-i
1.847.051
1.902.463
1.939.404
1.976.345
557
N-4-11-ii
3.121.472
3.215.116
3.277.546
3.339.975
558
N-4-11-iii
3.617.871
3.726.407
3.798.764
3.871.122
559
N-4-12-i
1.929.531
1.987.417
2.026.008
2.064.598
560
N-4-12-ii
2.894.297
2.981.126
3.039.012
3.096.897
561
N-4-12-iii
4.805.484
4.949.648
5.045.758
5.141.868
562
N-4-13-i
BATU URIN RINGAN
2.545.645
2.622.014
2.672.927
2.723.840
563
N-4-13-ii
BATU URIN SEDANG
3.069.090
3.161.163
3.222.545
3.283.927
564
N-4-13-iii
BATU URIN BERAT
7.558.327
7.785.077
7.936.244
8.087.410
1.671.332
1.721.472
1.754.898
1.788.325
2.573.640
2.650.850
2.702.322
2.753.795
4.173.624
4.298.833
4.382.306
4.465.778
2.479.551
2.553.937
2.603.528
2.653.119
565
N-4-14-i
566
N-4-14-ii
567
N-4-14-iii
568
N-4-15-i

(RINGAN)
(SEDANG)
(BERAT)
SALURAN URIN RINGAN
- 89 No
Kode
INA-CBG
569
N-4-15-ii
570
N-4-15-iii
571
N-4-16-i
572
N-4-16-ii
573
N-4-16-iii
574
O-6-10-i
575
O-6-10-ii
576
O-6-10-iii
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
584
585
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.402.715
3.504.797
3.572.851
3.640.905
3.883.112
3.999.605
4.077.268
4.154.930
3.218.114
3.314.658
3.379.020
3.443.382
3.859.062
3.974.834
4.052.015
4.129.197
8.115.034
8.358.485
8.520.786
8.683.086
4.751.704
4.894.256
4.989.290
5.084.324
5.275.116
5.433.370
5.538.872
5.644.374
5.913.469
6.090.873
6.209.142
6.327.411
2.483.411
2.557.913
2.607.581
2.657.249
3.185.989
3.281.569
3.345.289
3.409.008
5.399.263
5.561.241
5.669.226
5.777.211
2.162.566
2.227.443
2.270.694
2.313.945
2.597.236
2.675.153
2.727.098
2.779.042
3.263.055
3.360.946
3.426.208
3.491.469
2.167.281
2.232.299
2.275.645
2.318.990
O-6-13-ii
3.194.146
3.289.971
3.353.854
3.417.737
O-6-13-iii
3.774.988
3.888.237
3.963.737
4.039.237
48.481.088
49.935.521
50.905.143
51.874.764
59.987.763
61.787.396
62.987.151
64.186.906
70.408.818
72.521.082
73.929.258
75.337.435
58.738.622
60.500.781
61.675.553
62.850.326
67.379.246
69.400.623
70.748.208
72.095.793
76.985.606
79.295.174
80.834.886
82.374.598
3.249.059
3.346.530
3.411.511
3.476.493
4.548.682
4.685.142
4.776.116
4.867.090
7.165.206
7.380.162
7.523.466
7.666.770
29.016.375
29.886.866
30.467.193
31.047.521
37.656.998
38.786.708
39.539.848
40.292.988
53.990.657
55.610.377
56.690.190
57.770.003
586
P-8-01-i
587
P-8-01-ii
588
P-8-01-iii
589
P-8-02-i
590
P-8-02-ii
591
P-8-02-iii
592
P-8-03-i
593
P-8-03-ii
594
P-8-03-iii
595
P-8-04-i
596
P-8-04-ii
597
P-8-04-iii

SALURAN URIN SEDANG
SALURAN URIN BERAT
RINGAN
SEDANG
BERAT
&KURET RINGAN
KURET SEDANG
KURET BERAT

- 90 No
Kode
INA-CBG
598
P-8-05-i
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii
603
P-8-06-iii
604
P-8-07-i
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
614
P-8-11-ii
615
P-8-11-iii
616
P-8-12-i
617
P-8-12-ii
618
P-8-12-iii
619
P-8-13-i
620
P-8-13-ii
621
P-8-13-iii
622
P-8-14-i
623
P-8-14-ii
624
P-8-14-iii
625
P-8-15-i
Deskripsi (INA-CBG)
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
RINGAN
SEDANG
BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
ASPIRASI RINGAN
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
15.778.164
16.251.509
16.567.072
16.882.635
22.363.420
23.034.323
23.481.591
23.928.859
32.949.497
33.937.982
34.596.972
35.255.962
2.599.247
2.677.224
2.729.209
2.781.194
6.540.386
6.736.598
6.867.405
6.998.213
12.165.864
12.530.840
12.774.157
13.017.475
4.548.682
4.685.142
4.776.116
4.867.090
12.753.409
13.136.012
13.391.080
13.646.148
16.895.104
17.401.957
17.739.860
18.077.762
3.296.347
3.395.237
3.461.164
3.527.091
4.679.628
4.820.017
4.913.610
5.007.202
6.606.198
6.804.384
6.936.508
7.068.632
2.045.050
2.106.401
2.147.302
2.188.203
2.962.552
3.051.429
3.110.680
3.169.931
5.816.363
5.990.854
6.107.181
6.223.509
5.759.730
5.932.521
6.047.716
6.162.911
12.262.306
12.630.176
12.875.422
13.120.668
12.519.204
12.894.780
13.145.164
13.395.548
2.717.289
2.798.808
2.853.154
2.907.500
4.224.913
4.351.660
4.436.159
4.520.657
4.984.504
5.134.039
5.233.729
5.333.419
1.404.442
1.446.575
1.474.664
1.502.752
2.598.908
2.676.875
2.728.854
2.780.832
3.886.945
4.003.553
4.081.292
4.159.031
2.566.061
2.643.043
2.694.364
2.745.685
5.239.170
5.396.345
5.501.128
5.605.912
5.747.350
5.919.770
6.034.717
6.149.664
1.929.758
1.987.650
2.026.246
2.064.841
- 91 No
Kode
INA-CBG
626
P-8-15-ii
627
P-8-15-iii
628
P-8-16-i
629
P-8-16-ii
630
P-8-16-iii
631
P-8-17-i
632
P-8-17-ii
633
P-8-17-iii
634
S-4-10-i
635
S-4-10-ii
636
S-4-10-iii
637
S-4-11-i
638
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.857.078
3.972.791
4.049.932
4.127.074
4.530.736
4.666.658
4.757.272
4.847.887
1.746.887
1.799.293
1.834.231
1.869.169
2.478.034
2.552.375
2.601.935
2.651.496
3.216.609
3.313.108
3.377.440
3.441.772
1.152.941
1.187.530
1.210.589
1.233.647
3.829.682
3.944.572
4.021.166
4.097.759
7.729.968
7.961.867
8.116.467
8.271.066
1.929.531
1.987.417
2.026.008
2.064.598
2.411.914
2.484.271
2.532.510
2.580.748
3.135.074
3.229.126
3.291.828
3.354.529
1.205.957
1.242.136
1.266.255
1.290.374
S-4-11-ii
1.835.489
1.890.554
1.927.264
1.963.974
639
S-4-11-iii
2.969.501
3.058.586
3.117.976
3.177.366
640
S-4-12-i
1.447.148
1.490.563
1.519.506
1.548.449
641
S-4-12-ii
1.929.531
1.987.417
2.026.008
2.064.598
642
S-4-12-iii
3.768.527
3.881.583
3.956.953
4.032.324
1.929.531
1.987.417
2.026.008
2.064.598
3.410.978
3.513.308
3.581.527
3.649.747
6.945.186
7.153.541
7.292.445
7.431.349
1.175.628
1.210.897
1.234.409
1.257.922
2.497.428
2.572.351
2.622.299
2.672.248
4.736.013
4.878.093
4.972.814
5.067.534
889.138
915.812
933.595
951.378
1.678.107
1.728.450
1.762.012
1.795.574
2.173.538
2.238.744
2.282.215
2.325.686

ASPIRASI SEDANG
ASPIRASI BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT

PASIEN RINGAN
PASIEN SEDANG
PASIEN BERAT
643
S-4-13-i
644
S-4-13-ii
645
S-4-13-iii
646
S-4-14-i
647
S-4-14-ii
648
S-4-14-iii
649
S-4-15-i
650
S-4-15-ii
651
S-4-15-iii
652
S-4-16-i
LUKA BAKAR RINGAN
3.376.680
3.477.980
3.545.513
3.613.047
653
S-4-16-ii
LUKA BAKAR SEDANG
4.768.971
4.912.041
5.007.420
5.102.799
654
S-4-16-iii
LUKA BAKAR BERAT
8.515.739
8.771.211
8.941.526
9.111.841
1.800.512
1.854.527
1.890.537
1.926.548
2.411.914
2.484.271
2.532.510
2.580.748
3.933.102
4.051.095
4.129.757
4.208.419
655
S-4-17-i
656
S-4-17-ii
657
S-4-17-iii

- 92 No
Kode
INA-CBG
658
T-1-10-i
659
T-1-10-ii
660
T-1-10-iii
661
T-4-10-i
662
T-4-10-ii
663
T-4-10-iii
664
T-4-11-i
665
T-4-11-ii
666
T-4-11-iii
667
T-4-12-i
668
T-4-12-ii
669
T-4-12-iii
670
U-1-10-i
671
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.858.625
1.914.384
1.951.556
1.988.729
2.496.007
2.570.888
2.620.808
2.670.728
4.541.051
4.677.282
4.768.103
4.858.924
813.016
837.406
853.666
869.927
1.549.427
1.595.910
1.626.899
1.657.887
2.252.447
2.320.020
2.365.069
2.410.118
804.026
828.147
844.227
860.308
1.265.308
1.303.267
1.328.573
1.353.879
2.038.038
2.099.179
2.139.940
2.180.701
1.688.340
1.738.990
1.772.757
1.806.524
2.551.833
2.628.388
2.679.424
2.730.461
3.969.735
4.088.827
4.168.221
4.247.616
1.797.083
1.850.996
1.886.937
1.922.879
U-1-10-ii
3.667.058
3.777.070
3.850.411
3.923.752
672
U-1-10-iii
15.835.098
16.310.151
16.626.853
16.943.555
673
U-1-11-i
674
U-1-11-ii
675
U-1-11-iii
676

DOKTER RINGAN
DOKTER SEDANG
DOKTER BERAT

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
7.797.740
8.031.673
8.187.627
8.343.582
10.396.987
10.708.897
10.916.837
11.124.776
17.467.864
17.991.900
18.341.257
18.690.615
U-1-12-i
4.765.283
4.908.242
5.003.548
5.098.853
677
U-1-12-ii
11.696.611
12.047.509
12.281.441
12.515.373
678
U-1-12-iii
15.188.270
15.643.919
15.947.684
16.251.449
679
U-1-13-i
5.198.494
5.354.448
5.458.418
5.562.388
680
U-1-13-ii
5.865.311
6.041.271
6.158.577
6.275.883
681
U-1-13-iii
11.309.974
11.649.274
11.875.473
12.101.673
2.868.365
2.954.416
3.011.784
3.069.151
3.520.061
3.625.663
3.696.064
3.766.465
4.171.371
4.296.513
4.379.940
4.463.367

682
U-1-14-i
683
U-1-14-ii
684
U-1-14-iii
685
U-1-15-i
1.684.700
1.735.241
1.768.935
1.802.629
686
U-1-15-ii
2.393.842
2.465.657
2.513.534
2.561.410
687
U-1-15-iii
4.717.161
4.858.676
4.953.019
5.047.362
U-1-20-i

4.357.586
4.488.314
4.575.465
4.662.617
688
- 93 No
Kode
INA-CBG
689
U-1-20-ii
690
U-1-20-iii
691
U-1-30-i
692
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
7.756.503
7.989.198
8.144.328
8.299.458
19.135.576
19.709.643
20.092.355
20.475.066
3.738.049
3.850.190
3.924.951
3.999.712
U-1-30-ii
5.046.366
5.197.757
5.298.684
5.399.612
693
U-1-30-iii
9.892.328
10.189.098
10.386.945
10.584.791
694
U-4-10-i
3.479.499
3.583.884
3.653.474
3.723.064
695
U-4-10-ii
8.722.374
8.984.045
9.158.492
9.332.940
696
U-4-10-iii
12.724.044
13.105.765
13.360.246
13.614.727
697
U-4-11-i
1.929.531
1.987.417
2.026.008
2.064.598
698
U-4-11-ii
2.894.297
2.981.126
3.039.012
3.096.897
699
U-4-11-iii
4.002.801
4.122.885
4.202.941
4.282.997
700
U-4-12-i
1.929.531
1.987.417
2.026.008
2.064.598
701
U-4-12-ii
2.249.389
2.316.871
2.361.858
2.406.846
702
U-4-12-iii
3.576.426
3.683.719
3.755.247
3.826.776
703
U-4-13-i
1.895.622
1.952.491
1.990.403
2.028.316
704
U-4-13-ii
2.203.772
2.269.885
2.313.960
2.358.036
705
U-4-13-iii
2.502.221
2.577.288
2.627.332
2.677.377
706
U-4-14-i
2.411.914
2.484.271
2.532.510
2.580.748
707
U-4-14-ii
2.894.297
2.981.126
3.039.012
3.096.897
708
U-4-14-iii
4.848.449
4.993.903
5.090.872
5.187.841
709
U-4-15-i
1.929.531
1.987.417
2.026.008
2.064.598
710
U-4-15-ii
2.411.914
2.484.271
2.532.510
2.580.748
711
U-4-15-iii
3.377.334
3.478.654
3.546.201
3.613.747
712
V-1-10-i
5.640.659
5.809.879
5.922.692
6.035.505
713
V-1-10-ii
6.498.117
6.693.061
6.823.023
6.952.985
714
V-1-10-iii
12.346.422
12.716.815
12.963.744
13.210.672
715
V-1-11-i
6.498.117
6.693.061
6.823.023
6.952.985
716
V-1-11-ii
7.252.008
7.469.568
7.614.608
7.759.648
717
V-1-11-iii
10.739.113
11.061.286
11.276.069
11.490.851
3.509.506
3.614.791
3.684.981
3.755.171
13.412.165
13.814.530
14.082.773
14.351.016
15.659.924
16.129.722
16.442.921
16.756.119
5.319.273
5.478.851
5.585.237
5.691.622
718
V-1-12-i
719
V-1-12-ii
720
V-1-12-iii
721
V-1-13-i


DAN TELINGA RINGAN
DAN TELINGA SEDANG
DAN TELINGA BERAT


KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

- 94 No
Kode
INA-CBG
722
V-1-13-ii
723
V-1-13-iii
724
V-1-14-i
725
V-1-14-ii
726
V-1-14-iii
727
V-1-15-i
728
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
10.108.145
10.411.390
10.613.553
10.815.716
15.595.481
16.063.345
16.375.255
16.687.165
6.412.446
6.604.819
6.733.068
6.861.317
9.326.353
9.606.143
9.792.670
9.979.197
12.677.820
13.058.154
13.311.711
13.565.267
3.023.111
3.113.804
3.174.267
3.234.729
V-1-15-ii
5.758.438
5.931.191
6.046.360
6.161.529
729
V-1-15-iii
10.123.224
10.426.921
10.629.385
10.831.850
730
V-4-10-i
4.867.972
5.014.011
5.111.371
5.208.730
731
V-4-10-ii
6.287.567
6.476.194
6.601.946
6.727.697
732
V-4-10-iii
12.016.645
12.377.144
12.617.477
12.857.810
733
V-4-11-i
2.475.546
2.549.812
2.599.323
2.648.834
734
V-4-11-ii
3.617.168
3.725.683
3.798.027
3.870.370
735
V-4-11-iii
5.968.088
6.147.131
6.266.493
6.385.854
736
W-1-01-i
7.279.318
7.497.697
7.643.284
7.788.870
737
W-1-01-ii
8.767.593
9.030.621
9.205.973
9.381.324
738
W-1-01-iii
19.365.871
19.946.847
20.334.165
20.721.482
739
W-1-10-i
2.027.281
2.088.100
2.128.645
2.169.191
740
W-1-10-ii
3.783.239
3.896.737
3.972.401
4.048.066
741
W-1-10-iii
6.188.179
6.373.825
6.497.588
6.621.352
742
W-1-11-i
2.105.671
2.168.841
2.210.955
2.253.068
743
W-1-11-ii
4.061.053
4.182.885
4.264.106
4.345.327
744
W-1-11-iii
7.797.740
8.031.673
8.187.627
8.343.582
745
W-1-12-i
1.913.319
1.970.718
2.008.985
2.047.251
746
W-1-12-ii
2.175.407
2.240.669
2.284.177
2.327.685
747
W-1-12-iii
3.341.699
3.441.950
3.508.784
3.575.618
748
W-1-13-i
2.277.301
2.345.620
2.391.166
2.436.712
749
W-1-13-ii
2.472.493
2.546.668
2.596.118
2.645.567
750
W-1-13-iii
3.321.014
3.420.645
3.487.065
3.553.485
751
W-1-20-i
6.204.997
6.391.147
6.515.247
6.639.347
752
W-1-20-ii
8.728.260
8.990.108
9.164.673
9.339.238
753
W-1-20-iii
11.026.252
11.357.040
11.577.565
11.798.090

NON KOMPLEK (BERAT)

RINGAN
SEDANG
BERAT

SERVIK RINGAN
SERVIK SEDANG
SERVIK BERAT
ENDOSKOP RINGAN
ENDOSKOP SEDANG
ENDOSKOP BERAT
- 95 No
Kode
INA-CBG
754
W-1-30-i
755
W-1-30-ii
756
W-1-30-iii
757
W-4-10-i
758
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.387.306
3.488.926
3.556.672
3.624.418
5.402.929
5.565.017
5.673.075
5.781.134
14.367.717
14.798.749
15.086.103
15.373.457
2.526.082
2.601.864
2.652.386
2.702.908
W-4-10-ii
3.414.283
3.516.711
3.584.997
3.653.282
759
W-4-10-iii
7.718.125
7.949.668
8.104.031
8.258.393
760
W-4-11-i
2.411.914
2.484.271
2.532.510
2.580.748
761
W-4-11-ii
3.859.062
3.974.834
4.052.015
4.129.197
762
W-4-11-iii
4.689.904
4.830.602
4.924.400
5.018.198
763
W-4-12-i
1.929.531
1.987.417
2.026.008
2.064.598
764
W-4-12-ii
2.653.105
2.732.698
2.785.761
2.838.823
765
W-4-12-iii
2.957.918
3.046.655
3.105.814
3.164.972
766
W-4-13-i
ABORTUS RINGAN
1.058.178
1.089.923
1.111.087
1.132.250
767
W-4-13-ii
ABORTUS SEDANG
1.447.148
1.490.563
1.519.506
1.548.449
768
W-4-13-iii
ABORTUS BERAT
1.929.531
1.987.417
2.026.008
2.064.598
769
W-4-14-i
1.447.148
1.490.563
1.519.506
1.548.449
770
W-4-14-ii
1.861.266
1.917.104
1.954.330
1.991.555
771
W-4-14-iii
2.342.043
2.412.304
2.459.145
2.505.986
772
W-4-15-i
1.206.753
1.242.956
1.267.091
1.291.226
773
W-4-15-ii
1.342.140
1.382.404
1.409.247
1.436.089
774
W-4-15-iii
1.858.320
1.914.069
1.951.236
1.988.402
775
W-4-16-i
1.447.148
1.490.563
1.519.506
1.548.449
776
W-4-16-ii
1.929.531
1.987.417
2.026.008
2.064.598
777
W-4-16-iii
2.630.653
2.709.573
2.762.186
2.814.799
778
W-4-17-i
1.181.967
1.217.426
1.241.065
1.264.704
779
W-4-17-ii
1.929.531
1.987.417
2.026.008
2.064.598
780
W-4-17-iii
3.650.289
3.759.798
3.832.804
3.905.809
781
Z-4-10-i
REHABILITASI RINGAN
3.310.847
3.410.172
3.476.389
3.542.606
782
Z-4-10-ii
REHABILITASI SEDANG
4.394.671
4.526.512
4.614.405
4.702.298
783
Z-4-10-iii
REHABILITASI BERAT
6.243.050
6.430.341
6.555.202
6.680.063
784
Z-4-11-i
2.890.005
2.976.705
3.034.505
3.092.305
785
Z-4-11-ii
3.478.927
3.583.295
3.652.874
3.722.452
786
Z-4-11-iii
5.504.281
5.669.410
5.779.496
5.889.581
787
Z-4-12-i

1.447.148
1.490.563
1.519.506
1.548.449

RINGAN
SEDANG
BERAT

- 96 No
Kode
INA-CBG
788
Z-4-12-ii
789
Z-4-12-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.948.517
3.036.973
3.095.943
3.154.913
3.747.098
3.859.511
3.934.453
4.009.395
b. RawatJalan
- 97 -
No
Kode
INA-CBG
B-2-10-0
B-2-11-0
Deskripsi (INA-CBG)

LAPAROSKOPI
PANKREAS
LAPAROSKOPI
EMPEDU
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
800.166
824.171
840.174
856.178
1.037.940
1.069.079
1.089.837
1.110.596
1.930.187
1.988.093
2.026.696
2.065.300
1.595.112
1.642.966
1.674.868
1.706.770
1.332.579
1.372.556
1.399.208
1.425.859
467.208
481.224
490.568
499.913
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
1.041.813
1.073.067
1.093.903
1.114.739
B-3-12-0

214.058
220.480
224.761
229.042
C-3-10-0
583.921
601.438
613.117
624.795
10
C-3-11-0

KEMIH
923.492
951.197
969.667
988.137
11
C-3-12-0
209.354
215.634
219.822
224.009
12
C-3-13-0
203.297
209.396
213.462
217.528
13
C-3-14-0
1.730.670
1.782.590
1.817.203
1.851.817
14
C-3-15-0
1.586.228
1.633.815
1.665.539
1.697.264
15
C-3-16-0
359.718
370.510
377.704
384.899
16
C-3-17-0

LEHER
238.627
245.785
250.558
255.330
17
C-3-18-0
105.797
108.971
111.087
113.202
18
C-3-19-0

MYELOMA ATAU TESTIS
149.618
154.107
157.099
160.091
19
C-3-20-0
2.979.648
3.069.038
3.128.631
3.188.224
20
C-3-21-0
170.741
175.863
179.278
182.693
21
C-3-22-0
749.644
772.133
787.126
802.119
22
C-3-23-0
121.426
125.069
127.497
129.926
23
D-2-10-0

TULANG
1.028.737
1.059.599
1.080.174
1.100.749
24
D-2-11-0
PROSEDUR LIMPA
1.288.155
1.326.799
1.352.563
1.378.326
25
D-2-21-0
1.080.397
1.112.809
1.134.417
1.156.025
26
D-2-22-0
237.115
244.228
248.970
253.713
27
D-3-10-0
171.748
176.900
180.335
183.770
28
D-3-11-0
445.907
459.284
468.203
477.121
29
E-2-10-0
264.509
272.444
277.734
283.024
30
E-2-21-0
191.760
197.513
201.348
205.183
31
E-2-22-0
191.760
197.513
201.348
205.183

OVARIUM
GASTROINTESTINAL
GINJAL ATAU PROSTAT

TYMUS
TYMUS
TULANG
PEMBENTUK DARAH
PARATIROID
THYROGLOSSAL
- 98 No
Kode
INA-CBG
32
E-3-10-0
33
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

ENDOKRIN
223.004
229.694
234.155
238.615
F-3-10-0
TERAPI SHOCK
311.084
320.416
326.638
332.860
34
F-5-10-0
381.178
392.614
400.237
407.861
35
F-5-11-0
TERAPI KELOMPOK
251.352
258.893
263.920
268.947
36
F-5-12-0
321.648
331.297
337.730
344.163
37
F-5-13-0
272.414
280.587
286.035
291.483
38
F-5-14-0
182.753
188.236
191.891
195.546
39
F-5-15-0
171.446
176.590
180.019
183.447
40
F-5-16-0
178.578
183.935
187.507
191.078
41
G-2-10-0
PROSEDUR KRANIOTOMI
150.376
154.887
157.895
160.903
42
G-2-11-0
1.303.524
1.342.630
1.368.700
1.394.771
43
G-2-12-0

EKSTRAKRANIAL
1.889.128
1.945.801
1.983.584
2.021.366
44
G-2-13-0
463.445
477.348
486.617
495.886
45
G-2-21-0
845.246
870.603
887.508
904.413
46
G-2-22-0
767.132
790.146
805.489
820.832
47
G-2-31-0
1.265.835
1.303.810
1.329.127
1.354.444
48
G-2-32-0
648.866
668.332
681.309
694.287
49
G-3-10-0
257.539
265.265
270.416
275.567
50
G-3-11-0
342.993
353.282
360.142
367.002
51
G-3-12-0
561.999
578.859
590.099
601.339
52
G-3-13-0
562.063
578.925
590.167
601.408
53
H-2-21-0
737.625
759.754
774.506
789.259
54
H-2-22-0
191.760
197.513
201.348
205.183
55
H-2-23-0
191.760
197.513
201.348
205.183
56
H-2-31-0
1.221.814
1.258.469
1.282.905
1.307.341
57
H-2-32-0
127.162
130.977
133.520
136.064
58
H-2-33-0
191.760
197.513
201.348
205.183
59
H-2-34-0
548.136
564.580
575.542
586.505
60
H-2-35-0
180.623
186.042
189.654
193.267
61
H-2-36-0
974.961
1.004.210
1.023.710
1.043.209
62
H-2-37-0

1.037.889
1.069.026
1.089.784
1.110.542
63
H-3-10-0
361.110
371.943
379.165
386.387
64
H-3-11-0
189.904
195.601
199.399
203.197

AKUT
MENTAL

MATA
MATA
MATA
MATA
MATA
- 99 No
Kode
INA-CBG
65
H-3-12-0
66
H-3-13-0
67
I-2-11-0
68
I-2-12-0
69
I-2-13-0
70
I-2-14-0
71
I-2-15-0
Deskripsi (INA-CBG)
MATA
TORASIK
ABDOMEN
PENGGANTIAN ALAT
DARAH VENA
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
198.269
204.217
208.183
212.148
192.507
198.283
202.133
205.983
2.220.020
2.286.620
2.331.021
2.375.421
1.560.916
1.607.744
1.638.962
1.670.180
1.983.831
2.043.345
2.083.022
2.122.699
3.510.958
3.616.286
3.686.505
3.756.725
211.142
217.476
221.699
225.922
2.217.614
2.284.142
2.328.495
2.372.847
731.084
753.016
767.638
782.259
72
I-2-16-0
73
I-2-17-0
74
I-2-21-0
1.711.683
1.763.033
1.797.267
1.831.500
75
I-2-22-0
1.611.849
1.660.204
1.692.441
1.724.678
76
I-2-23-0
329.860
339.756
346.353
352.950
77
I-2-31-0
2.565.433
2.642.396
2.693.705
2.745.014
78
I-2-32-0
3.354.681
3.455.321
3.522.415
3.589.508
79
I-2-41-0
2.249.355
2.316.835
2.361.822
2.406.809
80
I-2-42-0

LAIN
2.615.247
2.693.704
2.746.009
2.798.314
81
I-3-10-0
PROSEDUR RESUSITASI
331.982
341.942
348.581
355.221
82
I-3-11-0
175.220
180.476
183.981
187.485
83
I-3-12-0
1.018.310
1.048.859
1.069.225
1.089.591
84
I-3-13-0
334.452
344.486
351.175
357.864
85
I-3-14-0
214.373
220.804
225.091
229.379
189.904
195.601
199.399
203.197
1.175.761
1.211.034
1.234.549
1.258.065
189.532
195.218
199.009
202.800
955.125
983.779
1.002.882
1.021.984
1.238.883
1.276.050
1.300.827
1.325.605

PACU JANTUNG

KARDIOVASKULAR
PERNAFASAN
PENDEK
86
I-3-15-0
87
J-2-10-0
88
J-2-21-0
89
J-2-22-0
90
J-2-31-0
91
J-2-32-0
921.935
949.593
968.031
986.470
92
J-3-10-0
191.760
197.513
201.348
205.183
93
J-3-11-0

PADA DADA
541.879
558.136
568.973
579.811
94
J-3-12-0
209.354
215.634
219.822
224.009
95
J-3-13-0
308.117
317.360
323.522
329.685
96
J-3-14-0
327.099
336.912
343.454
349.996
- 100 No
Kode
INA-CBG
97
J-3-15-0
98
J-3-16-0
99
J-3-17-0
100
K-2-10-0
101
K-2-11-0
102
K-2-12-0

103
K-2-13-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
286.840
295.445
301.182
306.919
327.099
336.912
343.454
349.996
191.760
197.513
201.348
205.183
551.950
568.509
579.548
590.587
1.178.639
1.213.999
1.237.571
1.261.144
904.758
931.900
949.996
968.091
1.472.542
1.516.718
1.546.169
1.575.620
191.760
197.513
201.348
205.183
191.760
197.513
201.348
205.183
2.464.571
2.538.508
2.587.799
2.637.091
828.710
853.571
870.145
886.719
191.760
197.513
201.348
205.183

PERNAFASAN
KECIL

FEMORALIS
USUS BESAR
ATAS
ATAS
104
K-2-14-0
105
K-2-21-0
106
K-2-22-0
107
K-2-31-0
108
K-2-32-0
109
K-2-41-0
912.841
940.226
958.483
976.740
110
K-2-42-0

260.810
268.634
273.850
279.067
111
K-2-51-0
604.904
623.051
635.149
647.247
112
K-2-52-0
329.860
339.756
346.353
352.950
113
K-2-53-0
191.760
197.513
201.348
205.183
114
K-3-10-0

GASTROINTESTINAL
364.906
375.853
383.151
390.450
115
K-3-11-0
219.380
225.961
230.349
234.736
116
K-3-12-0
222.479
229.153
233.603
238.052
117
K-3-13-0
191.760
197.513
201.348
205.183
513.921
529.338
539.617
549.895
248.179
255.625
260.588
265.552
328.854
338.719
345.296
351.873
1.130.610
1.164.529
1.187.141
1.209.753
724.713
746.455
760.949
775.443
327.099
336.912
343.454
349.996
329.860
339.756
346.353
352.950

GASTROINTESTINAL
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
118
K-3-14-0
119
K-3-15-0
120
K-3-16-0
121
L-2-21-0
122
L-2-22-0
123
L-2-31-0
124
L-2-32-0
125
L-2-41-0
987.727
1.017.359
1.037.113
1.056.868
126
L-2-42-0

221.531
228.177
232.608
237.038
127
L-2-51-0
1.478.782
1.523.145
1.552.721
1.582.297
L-2-52-0

1.131.317
1.165.256
1.187.883
1.210.509
128
- 101 No
Kode
INA-CBG
129
L-2-53-0
130
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

191.760
197.513
201.348
205.183
L-3-10-0
260.810
268.634
273.850
279.067
131
L-3-11-0
253.264
260.862
265.928
270.993
132
L-3-12-0
192.885
198.672
202.529
206.387
133
M-2-10-0
3.470.660
3.574.779
3.644.193
3.713.606
134
M-2-21-0
3.108.216
3.201.462
3.263.627
3.325.791
135
M-2-22-0
756.713
779.414
794.548
809.683
136
M-2-31-0
PROSEDUR BUNION
1.887.929
1.944.567
1.982.325
2.020.084
137
M-2-32-0
598.309
616.258
628.224
640.191
138
M-2-41-0

TULANG
598.309
616.258
628.224
640.191
139
M-2-42-0
206.194
212.380
216.503
220.627
140
M-2-51-0
439.905
453.102
461.900
470.698
141
M-2-52-0
439.905
453.102
461.900
470.698
142
M-2-61-0
PROSEDUR ARTROSKOPI
2.156.205
2.220.891
2.264.015
2.307.139
143
M-2-62-0
439.905
453.102
461.900
470.698
2.167.869
2.232.905
2.276.263
2.319.620
2.956.526
3.045.222
3.104.352
3.163.483
439.905
453.102
461.900
470.698
2.182.693
2.248.174
2.291.828
2.335.482
2.106.392
2.169.584
2.211.712
2.253.840

DAN WAJAH
PAHA
PAHA

TULANG
WAJAH
WAJAH
BAWAH
BAWAH
144
M-2-63-0
145
M-2-64-0
146
M-2-65-0
147
M-2-71-0
148
M-2-72-0
149
M-2-81-0
3.141.079
3.235.311
3.298.133
3.360.955
150
M-2-82-0
2.281.792
2.350.246
2.395.882
2.441.518
151
M-2-83-0
439.905
453.102
461.900
470.698
152
M-2-84-0
439.905
453.102
461.900
470.698
153
M-3-10-0
1.255.574
1.293.241
1.318.353
1.343.464
154
M-3-11-0
696.139
717.023
730.946
744.869
155
M-3-12-0
1.574.266
1.621.494
1.652.979
1.684.464
156
M-3-13-0
513.253
528.651
538.916
549.181
157
M-3-14-0

TERTUTUP
877.236
903.553
921.098
938.643
158
M-3-15-0
386.476
398.071
405.800
413.530
159
M-3-16-0

439.905
453.102
461.900
470.698
160
M-3-17-0
480.266
494.674
504.280
513.885
161
N-2-11-0
2.533.336
2.609.336
2.660.002
2.710.669

PERGELANGAN TANGAN
PERGELANGAN TANGAN
MUSKULOSKELETAL
SKELETAL
- 102 No
Kode
INA-CBG
162
N-2-12-0
163
N-2-21-0
164
N-2-22-0
165
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.465.510
1.509.475
1.538.785
1.568.095
1.457.785
1.501.518
1.530.674
1.559.830
329.860
339.756
346.353
352.950
N-2-23-0
329.860
339.756
346.353
352.950
166
N-2-24-0
1.065.997
1.097.977
1.119.297
1.140.617
167
N-2-31-0
897.397
924.319
942.267
960.214
168
N-2-32-0
329.860
339.756
346.353
352.950
169
N-2-41-0
329.860
339.756
346.353
352.950
170
N-2-42-0
557.857
574.592
585.749
596.907
171
N-3-10-0
329.860
339.756
346.353
352.950
172
N-3-11-0
382.190
393.656
401.300
408.943
173
N-3-12-0
295.335
304.195
310.102
316.008
174
N-3-13-0
329.860
339.756
346.353
352.950
175
N-3-14-0
283.827
292.341
298.018
303.695
176
N-3-15-0
727.803
749.637
764.193
778.749
177
O-7-10-0
121.512
125.157
127.587
130.018
178
O-7-11-0
669.197
689.273
702.657
716.041
179
O-7-12-0
243.677
250.988
255.861
260.735
180
O-7-13-0
135.425
139.488
142.196
144.905
181
P-9-10-0
180.623
186.042
189.654
193.267
182
P-9-11-0
180.623
186.042
189.654
193.267
183
P-9-12-0
180.623
186.042
189.654
193.267
184
P-9-13-0
180.623
186.042
189.654
193.267
185
P-9-14-0
180.623
186.042
189.654
193.267
186
P-9-15-0
115.133
118.587
120.890
123.192
187
P-9-16-0
180.623
186.042
189.654
193.267
188
P-9-17-0
179.846
185.242
188.839
192.436
189
Q-5-10-0
235.410
242.472
247.180
251.888
190
Q-5-11-0
176.433
181.726
185.255
188.783
191
Q-5-12-0
GIGI
155.503
160.169
163.279
166.389
192
Q-5-13-0
MEDICAL CHECK-UP
118.176
121.721
124.085
126.448
193
Q-5-14-0
130.032
133.933
136.534
139.134


DAN URETHRA
URETHRA
TRANSURETHRA
TRANSURETHRA
SALURAN KEMIH
KEMIH
KEMIH
PROSEDUR DIALISIS
CAESAR
VAGINAL/JALAN LAHIR

ASPIRASI
- 103 No
Kode
INA-CBG
194
Q-5-15-0
195
Q-5-16-0
VAKSINASI
196
Q-5-17-0
PASANG INFUS
197
Q-5-18-0
198
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
89.423
92.106
93.894
95.683
101.069
104.101
106.122
108.143
87.422
90.044
91.793
93.541
164.555
169.492
172.783
176.074
Q-5-19-0
183.963
189.481
193.161
196.840
199
Q-5-20-0
ABORSI MENGANCAM
123.304
127.003
129.469
131.935
200
Q-5-21-0
ABORSI
121.625
125.273
127.706
130.138
201
Q-5-22-0
130.032
133.933
136.534
139.134
202
Q-5-23-0
159.194
163.969
167.153
170.337
203
Q-5-24-0
108.727
111.989
114.163
116.338
204
Q-5-25-0
169.557
174.644
178.035
181.426
205
Q-5-26-0
BRONKIAL AKUT
239.997
247.197
251.997
256.797
206
Q-5-27-0
170.793
175.917
179.333
182.749
207
Q-5-28-0
138.594
142.752
145.524
148.296
208
Q-5-29-0

JANTUNG LAIN-LAIN
392.384
404.155
412.003
419.850
209
Q-5-30-0
454.730
468.372
477.467
486.561
210
Q-5-31-0
FRAKTUR
162.230
167.096
170.341
173.586
211
Q-5-32-0
SALURAN KEMIH AKUT
187.898
193.535
197.293
201.051
212
Q-5-33-0
HEMATOLOGI AKUT
196.729
202.631
206.565
210.500
213
Q-5-34-0
INFEKSI VIRUS HIV
279.467
287.851
293.441
299.030
214
Q-5-35-0
INFEKSI AKUT
316.908
326.416
332.754
339.092
215
Q-5-36-0
369.060
380.132
387.513
394.894
216
Q-5-37-0

SHOCK
188.240
193.887
197.652
201.416
217
Q-5-38-0
PARU AKUT
251.024
258.554
263.575
268.595
218
Q-5-39-0
160.637
165.456
168.668
171.881
219
Q-5-40-0
157.610
162.339
165.491
168.643
220
Q-5-41-0
218.189
224.735
229.098
233.462
221
Q-5-42-0
171.069
176.201
179.622
183.044
222
Q-5-43-0
246.349
253.739
258.666
263.593
223
Q-5-44-0
201.055
207.087
211.108
215.129
224
T-2-10-0

TERAPI DETOKSIKASI
104.284
107.412
109.498
111.584
225
U-2-10-0
1.391.785
1.433.539
1.461.375
1.489.210
226
U-2-11-0

LEHER
1.654.292
1.703.920
1.737.006
1.770.092
227
U-2-12-0
182.015
187.476
191.116
194.756
- 104 No
Kode
INA-CBG
228
U-2-13-0
229
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
238.627
245.785
250.558
255.330
U-2-14-0
443.260
456.558
465.423
474.288
230
U-2-15-0
251.851
259.406
264.443
269.480
231
U-2-21-0
293.367
302.168
308.035
313.902
232
U-2-22-0
566.808
583.812
595.148
606.484
233
U-2-23-0
742.701
764.982
779.836
794.690
234
U-2-24-0
625.936
644.714
657.233
669.751
235
U-2-25-0
238.627
245.785
250.558
255.330
236
U-2-31-0
191.760
197.513
201.348
205.183
237
U-2-32-0
238.627
245.785
250.558
255.330
238
U-3-10-0
228.140
234.984
239.546
244.109
239
U-3-11-0
242.213
249.479
254.324
259.168
240
U-3-12-0
107.106
110.319
112.462
114.604
241
U-3-13-0
235.428
242.491
247.199
251.908
242
U-3-14-0
216.310
222.799
227.125
231.451
243
U-3-15-0
188.641
194.301
198.073
201.846
244
U-3-16-0
PROSEDUR PADA GIGI
212.753
219.136
223.391
227.646
245
V-2-10-0

PROSTAT
2.075.654
2.137.923
2.179.436
2.220.949
246
V-2-11-0
PROSEDUR PADA PENIS
234.081
241.103
245.785
250.467
746.986
769.395
784.335
799.275
329.860
339.756
346.353
352.950
329.860
339.756
346.353
352.950

(RHINOPLASTY)

RONGGA HIDUNG
TENGGOROKAN

SKROTUM
SKROTUM
TRANSURETHRAL
247
V-2-12-0
248
V-2-13-0
249
V-2-14-0
250
V-2-15-0
SIRKUMSISI/SUNAT
180.623
186.042
189.654
193.267
251
V-3-10-0
376.702
388.003
395.537
403.071
252
V-3-11-0
796.919
820.827
836.765
852.704
253
V-3-12-0
460.083
473.885
483.087
492.288
254
W-2-10-0
168.470
173.524
176.893
180.262
255
W-2-11-0
430.545
443.462
452.073
460.684
256
W-2-12-0
796.919
820.827
836.765
852.704
257
W-2-13-0
127.812
131.646
134.202
136.758
258
W-2-21-0
1.602.020
1.650.081
1.682.121
1.714.162
259
W-2-22-0
168.470
173.524
176.893
180.262

PROSEDUR ABORSI
RAHIM & LEHER RAHIM
TERHALANG/TERGANGGU
TERHALANG/TERGANGGU
PANGGUL TERBUKA
PANGGUL TERBUKA
- 105 No
Kode
INA-CBG
260
W-2-23-0
Deskripsi (INA-CBG)
JALAN LAHIR
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
562.191
579.057
590.301
601.545
1.845.502
1.900.867
1.937.777
1.974.688
1.294.335
1.333.165
1.359.051
1.384.938
261
W-2-31-0
262
W-2-32-0
263
W-2-33-0
550.109
566.613
577.615
588.617
264
W-2-34-0
187.102
192.715
196.457
200.199
265
W-3-10-0
454.730
468.372
477.466
486.561
266
W-3-11-0
363.498
374.403
381.673
388.943
267
W-3-12-0
168.470
173.524
176.893
180.262
268
Z-3-10-0
1.907.300
1.964.519
2.002.665
2.040.811
269
Z-3-11-0

EMPEDU
1.457.785
1.501.518
1.530.674
1.559.830
270
Z-3-12-0
243.415
250.717
255.586
260.454
271
Z-3-13-0

LAIN-LAIN
1.485.384
1.529.945
1.559.653
1.589.361
272
Z-3-14-0
DIAGNOSTIK TIDUR
293.706
302.518
308.392
314.266
273
Z-3-15-0
191.760
197.513
201.348
205.183
274
Z-3-16-0

(MRI)
615.491
633.956
646.265
658.575
275
Z-3-17-0
PENGOBATAN NUKLIR
258.396
266.148
271.316
276.484
276
Z-3-18-0
CT-SCAN KEPALA
248.960
256.429
261.408
266.387
277
Z-3-19-0
CT SCAN LAIN-LAIN
259.119
266.892
272.075
277.257
278
Z-3-20-0
176.233
181.520
185.045
188.569
279
Z-3-21-0
168.470
173.524
176.893
180.262
280
Z-3-22-0
189.934
195.632
199.431
203.230
281
Z-3-23-0
197.833
203.768
207.725
211.681
282
Z-3-24-0
388.703
400.364
408.138
415.912
283
Z-3-25-0
173.128
178.321
181.784
185.247
284
Z-3-26-0
195.668
201.538
205.452
209.365
285
Z-3-27-0
PERAWATAN LUKA
186.810
192.415
196.151
199.887
286
Z-3-28-0
IMAGING PAYUDARA
191.760
197.513
201.348
205.183
287
Z-3-29-0
IMAGING LAIN-LAIN
552.686
569.267
580.321
591.375
288
Z-3-30-0
FOTOTERAPI
93.273
96.071
97.937
99.802
- 106 3. RUMAH SAKIT MATA KELAS A

a. RawatInap
No
Kode
INA-CBG
A-4-10-i
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
SEPTIKEMIA RINGAN
2.736.833
2.818.938
2.873.675
2.928.411
A-4-10-ii
SEPTIKEMIA SEDANG
3.132.938
3.226.926
3.289.585
3.352.244
A-4-10-iii
SEPTIKEMIA BERAT
4.911.856
5.059.212
5.157.449
5.255.686
A-4-11-i
4.918.728
5.066.290
5.164.664
5.263.039
A-4-11-ii
7.598.866
7.826.832
7.978.809
8.130.787
A-4-11-iii
12.430.084
12.802.987
13.051.589
13.300.190
A-4-12-i
DEMAM RINGAN
1.929.531
1.987.417
2.026.008
2.064.598
A-4-12-ii
DEMAM SEDANG
2.767.495
2.850.520
2.905.870
2.961.219
A-4-12-iii
DEMAM BERAT
3.167.195
3.262.211
3.325.555
3.388.898
10
A-4-13-i
2.411.914
2.484.271
2.532.510
2.580.748
11
A-4-13-ii
2.894.297
2.981.126
3.039.012
3.096.897
12
A-4-13-iii
3.517.676
3.623.206
3.693.559
3.763.913
1.929.531
1.987.417
2.026.008
2.064.598
3.064.499
3.156.434
3.217.723
3.279.013
3.489.611
3.594.300
3.664.092
3.733.884

LAIN-LAIN RINGAN
LAIN-LAIN SEDANG
LAIN-LAIN BERAT
13
A-4-14-i
14
A-4-14-ii
15
A-4-14-iii
16
A-4-15-i
INFEKSI HIV RINGAN
2.894.297
2.981.126
3.039.012
3.096.897
17
A-4-15-ii
INFEKSI HIV SEDANG
4.341.445
4.471.688
4.558.517
4.645.346
18
A-4-15-iii
INFEKSI HIV BERAT
6.037.927
6.219.065
6.339.824
6.460.582
19
B-1-01-i
32.087.791
33.050.425
33.692.181
34.333.937
20
B-1-01-ii
35.401.413
36.463.455
37.171.483
37.879.512
21
B-1-01-iii
62.101.363
63.964.404
65.206.431
66.448.458
22
B-1-10-i
4.160.073
4.284.875
4.368.077
4.451.278
23
B-1-10-ii
10.601.870
10.919.927
11.131.964
11.344.001
24
B-1-10-iii
18.453.662
19.007.272
19.376.345
19.745.418
2.843.954
2.929.272
2.986.151
3.043.030
7.138.592
7.352.750
7.495.521
7.638.293
8.950.023
9.218.523
9.397.524
9.576.524
6.066.256
6.248.243
6.369.568
6.490.893
13.001.469
13.391.514
13.651.543
13.911.572
15.823.278
16.297.977
16.614.442
16.930.908
3.975.082
4.094.335
4.173.836
4.253.338
25
B-1-11-i
26
B-1-11-ii
27
B-1-11-iii
28
B-1-12-i
29
B-1-12-ii
30
B-1-12-iii
31
B-1-13-i

(RINGAN)
(SEDANG)
(BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT
LAIN-LAIN (RINGAN)
- 107 No
Kode
INA-CBG
32
B-1-13-ii
33
B-1-13-iii
34
B-1-14-i
35
B-1-14-ii
36
B-1-14-iii
37
B-4-10-i
38
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
6.474.832
6.669.077
6.798.574
6.928.070
9.545.719
9.832.091
10.023.005
10.213.920
5.397.882
5.559.818
5.667.776
5.775.734
6.003.534
6.183.640
6.303.711
6.423.781
9.391.815
9.673.570
9.861.406
10.049.242
1.509.610
1.554.898
1.585.090
1.615.282
B-4-10-ii
2.411.914
2.484.271
2.532.510
2.580.748
39
B-4-10-iii
3.687.530
3.798.156
3.871.907
3.945.657
40
B-4-11-i
3.646.298
3.755.687
3.828.613
3.901.539
41
B-4-11-ii
5.543.284
5.709.582
5.820.448
5.931.313
42
B-4-11-iii
5.970.309
6.149.418
6.268.824
6.388.231
43
B-4-12-i
3.199.377
3.295.358
3.359.346
3.423.333
44
B-4-12-ii
4.535.929
4.672.007
4.762.725
4.853.444
45
B-4-12-iii
8.815.985
9.080.465
9.256.785
9.433.104
46
B-4-13-i
2.894.297
2.981.126
3.039.012
3.096.897
47
B-4-13-ii
4.516.709
4.652.210
4.742.544
4.832.878
48
B-4-13-iii
6.855.406
7.061.068
7.198.176
7.335.284
49
B-4-14-i
2.894.297
2.981.126
3.039.012
3.096.897
50
B-4-14-ii
3.376.680
3.477.980
3.545.513
3.613.047
51
B-4-14-iii
4.504.830
4.639.975
4.730.072
4.820.168
52
C-4-10-i
2.818.461
2.903.015
2.959.384
3.015.753
53
C-4-10-ii
5.475.974
5.640.253
5.749.772
5.859.292
54
C-4-10-iii
LEUKEMIA AKUT BERAT
9.165.273
9.440.231
9.623.537
9.806.842
55
C-4-11-i
2.894.297
2.981.126
3.039.012
3.096.897
56
C-4-11-ii
3.859.062
3.974.834
4.052.015
4.129.197
57
C-4-11-iii
6.560.858
6.757.683
6.888.901
7.020.118
58
C-4-12-i
RADIOTERAPI RINGAN
1.929.531
1.987.417
2.026.008
2.064.598
59
C-4-12-ii
RADIOTERAPI SEDANG
5.312.582
5.471.959
5.578.211
5.684.463
60
C-4-12-iii
RADIOTERAPI BERAT
10.785.606
11.109.174
11.324.886
11.540.598
61
C-4-13-i
KEMOTERAPI RINGAN
1.929.531
1.987.417
2.026.008
2.064.598
62
C-4-13-ii
KEMOTERAPI SEDANG
3.859.062
3.974.834
4.052.015
4.129.197
63
C-4-13-iii
KEMOTERAPI BERAT
5.049.298
5.200.776
5.301.762
5.402.748
64
C-4-14-i

RINGAN
2.502.086
2.577.148
2.627.190
2.677.232

LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT

PANCREAS RINGAN
PANCREAS SEDANG
PANCREAS BERAT
(RINGAN)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT
- 108 No
Kode
INA-CBG
65
C-4-14-ii
66
C-4-14-iii
67
D-1-10-i
68
D-1-10-ii
69
D-1-10-iii
70
D-1-11-i
71
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.656.208
3.765.894
3.839.018
3.912.142
5.573.783
5.740.996
5.852.472
5.963.947
20.532.500
21.148.475
21.559.125
21.969.775
31.272.572
32.210.749
32.836.201
33.461.652
42.382.880
43.654.367
44.502.024
45.349.682
4.220.279
4.346.887
4.431.293
4.515.698
D-1-11-ii
11.007.262
11.337.480
11.557.625
11.777.770
72
D-1-11-iii
15.595.481
16.063.345
16.375.255
16.687.165
73
D-1-20-i
5.198.494
5.354.448
5.458.418
5.562.388
74
D-1-20-ii
11.696.611
12.047.509
12.281.441
12.515.373
75
D-1-20-iii
21.143.560
21.777.867
22.200.738
22.623.609
76
D-4-10-i
1.853.433
1.909.036
1.946.105
1.983.174
77
D-4-10-ii
3.742.430
3.854.703
3.929.552
4.004.400
78
D-4-10-iii
4.823.828
4.968.543
5.065.019
5.161.496
79
D-4-11-i
4.220.849
4.347.475
4.431.892
4.516.309
80
D-4-11-ii
7.543.794
7.770.107
7.920.983
8.071.859
81
D-4-11-iii
10.327.905
10.637.742
10.844.300
11.050.859
82
D-4-12-i
2.474.164
2.548.388
2.597.872
2.647.355
83
D-4-12-ii
3.431.908
3.534.865
3.603.503
3.672.142
84
D-4-12-iii
5.269.697
5.427.787
5.533.181
5.638.575
85
D-4-13-i
1.929.531
1.987.417
2.026.008
2.064.598
86
D-4-13-ii
2.894.297
2.981.126
3.039.012
3.096.897
87
D-4-13-iii
3.376.680
3.477.980
3.545.513
3.613.047
88
D-4-14-i
2.324.850
2.394.595
2.441.092
2.487.589
89
D-4-14-ii
5.427.955
5.590.794
5.699.353
5.807.912
90
D-4-14-iii
6.474.800
6.669.044
6.798.540
6.928.036
91
E-1-01-i
4.625.290
4.764.049
4.856.555
4.949.060
92
E-1-01-ii
6.058.690
6.240.451
6.361.625
6.482.798
93
E-1-01-iii
13.732.161
14.144.126
14.418.769
14.693.413
94
E-1-10-i
4.712.923
4.854.311
4.948.569
5.042.828
95
E-1-10-ii
5.720.382
5.891.994
6.006.401
6.120.809
96
E-1-10-iii
12.056.882
12.418.588
12.659.726
12.900.864
97
E-1-20-i

5.457.662
5.621.392
5.730.546
5.839.699

SEDANG
BERAT
TULANG RINGAN
TULANG SEDANG
TULANG BERAT


RINGAN
SEDANG
BERAT
- 109 No
Kode
INA-CBG
98
E-1-20-ii
99
E-1-20-iii
100
E-4-10-i
101
E-4-10-ii
102
E-4-10-iii
103
E-4-11-i
104
E-4-11-ii
105
E-4-11-iii
106
E-4-12-i
107
E-4-12-ii
108
E-4-12-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
7.309.657
7.528.947
7.675.140
7.821.333
16.196.134
16.682.018
17.005.941
17.329.864
2.411.914
2.484.271
2.532.510
2.580.748
3.430.249
3.533.157
3.601.762
3.670.367
6.556.854
6.753.560
6.884.697
7.015.834
2.057.867
2.119.603
2.160.760
2.201.918
3.893.131
4.009.925
4.087.788
4.165.650
6.419.952
6.612.551
6.740.950
6.869.349
2.458.864
2.532.629
2.581.807
2.630.984
4.271.509
4.399.655
4.485.085
4.570.515
6.975.048
7.184.299
7.323.800
7.463.301
2.593.620
2.671.428
2.723.301
2.775.173
4.453.263
4.586.861
4.675.926
4.764.992
7.705.270
7.936.428
8.090.534
8.244.639

RINGAN
SEDANG
BERAT

RINGAN
SEDANG
BERAT
109
E-4-13-i
110
E-4-13-ii
111
E-4-13-iii
112
F-4-10-i
SCHIZOFRENIA RINGAN
3.171.191
3.266.326
3.329.750
3.393.174
113
F-4-10-ii
SCHIZOFRENIA SEDANG
3.521.709
3.627.361
3.697.795
3.768.229
114
F-4-10-iii
SCHIZOFRENIA BERAT
5.213.968
5.370.387
5.474.667
5.578.946
115
F-4-11-i
2.923.070
3.010.762
3.069.223
3.127.685
116
F-4-11-ii
3.405.654
3.507.823
3.575.936
3.644.050
117
F-4-11-iii
DEPRESI MAYOR BERAT
4.367.293
4.498.312
4.585.657
4.673.003
1.447.148
1.490.563
1.519.506
1.548.449
2.066.323
2.128.312
2.169.639
2.210.965
4.482.540
4.617.016
4.706.667
4.796.318

IMPULSE RINGAN
IMPULSE SEDANG
IMPULSE BERAT
118
F-4-12-i
119
F-4-12-ii
120
F-4-12-iii
121
F-4-13-i
2.362.284
2.433.153
2.480.399
2.527.644
122
F-4-13-ii
3.128.272
3.222.120
3.284.685
3.347.251
123
F-4-13-iii
4.033.507
4.154.512
4.235.182
4.315.852
124
F-4-14-i
DEPRESI RINGAN
1.653.599
1.703.207
1.736.279
1.769.351
125
F-4-14-ii
DEPRESI SEDANG
2.121.076
2.184.709
2.227.130
2.269.552
126
F-4-14-iii
DEPRESI BERAT
2.854.003
2.939.623
2.996.703
3.053.783
127
F-4-15-i
1.966.035
2.025.016
2.064.337
2.103.658
128
F-4-15-ii
2.894.297
2.981.126
3.039.012
3.096.897
129
F-4-15-iii
3.811.966
3.926.325
4.002.565
4.078.804
F-4-16-i

4.234.455
4.361.489
4.446.178
4.530.867
130
- 110 No
Kode
INA-CBG
131
F-4-16-ii
132
F-4-16-iii
133
F-4-17-i
134
F-4-17-ii
135
F-4-17-iii
136
F-4-18-i
137
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.922.448
5.070.122
5.168.571
5.267.020
6.570.647
6.767.766
6.899.179
7.030.592
977.686
1.007.016
1.026.570
1.046.124
2.865.503
2.951.468
3.008.779
3.066.089
3.057.281
3.149.000
3.210.145
3.271.291
3.670.283
3.780.392
3.853.797
3.927.203
F-4-18-ii
4.038.348
4.159.499
4.240.265
4.321.032
138
F-4-18-iii
6.225.466
6.412.230
6.536.739
6.661.248
139
F-4-19-i
2.814.761
2.899.204
2.955.499
3.011.794
140
F-4-19-ii
3.604.374
3.712.505
3.784.592
3.856.680
141
F-4-19-iii
4.487.493
4.622.118
4.711.868
4.801.618
142
G-1-01-i
8.948.725
9.217.187
9.396.162
9.575.136
143
G-1-01-ii
15.146.796
15.601.200
15.904.136
16.207.072
144
G-1-01-iii
29.322.505
30.202.181
30.788.631
31.375.081
145
G-1-10-i
4.465.865
4.599.841
4.689.159
4.778.476
146
G-1-10-ii
6.304.692
6.493.832
6.619.926
6.746.020
147
G-1-10-iii
7.472.406
7.696.578
7.846.027
7.995.475
148
G-1-11-i
5.151.509
5.306.054
5.409.084
5.512.115
149
G-1-11-ii
10.579.012
10.896.382
11.107.962
11.319.543
150
G-1-11-iii
22.151.489
22.816.034
23.259.063
23.702.093
151
G-1-12-i
4.006.356
4.126.547
4.206.674
4.286.801
152
G-1-12-ii
9.172.154
9.447.318
9.630.761
9.814.204
153
G-1-12-iii
16.177.668
16.662.998
16.986.551
17.310.104
154
G-1-13-i
1.056.601
1.088.299
1.109.431
1.130.563
155
G-1-13-ii
2.837.914
2.923.052
2.979.810
3.036.568
156
G-1-13-iii
6.403.530
6.595.636
6.723.706
6.851.777
157
G-1-20-i
5.048.350
5.199.800
5.300.767
5.401.734
158
G-1-20-ii
6.820.486
7.025.100
7.161.510
7.297.920
159
G-1-20-iii
16.699.157
17.200.132
17.534.115
17.868.098
160
G-1-30-i
6.438.715
6.631.877
6.760.651
6.889.426
161
G-1-30-ii
16.805.665
17.309.835
17.645.948
17.982.061
162
G-1-30-iii
21.634.084
22.283.106
22.715.788
23.148.470
G-4-10-i

BELAKANG RINGAN
2.894.297
2.981.126
3.039.012
3.096.897
163

RINGAN
SEDANG
BERAT

KRANIAL RINGAN
PROSEDUR PEMBULUH DARAH INTRA KRANIAL
SEDANG
PROSEDUR PEMBULUH DARAH INTRA KRANIAL
BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

RINGAN
SEDANG
BERAT
- 111 No
Kode
INA-CBG
164
G-4-10-ii
165
G-4-10-iii
166
G-4-11-i
167
G-4-11-ii
168
G-4-11-iii
169
G-4-12-i
170
G-4-12-ii
171
G-4-12-iii
172
G-4-13-i
173
G-4-13-ii
174
G-4-13-iii
175
G-4-14-i
176
G-4-14-ii
177
G-4-14-iii
178
G-4-15-i
179
G-4-15-ii
180
G-4-15-iii
181
G-4-16-i
182
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.376.680
3.477.980
3.545.513
3.613.047
5.158.630
5.313.389
5.416.561
5.519.734
9.273.858
9.552.073
9.737.551
9.923.028
10.757.675
11.080.405
11.295.559
11.510.712
15.765.558
16.238.525
16.553.836
16.869.147
3.571.566
3.678.713
3.750.144
3.821.575
4.500.173
4.635.178
4.725.181
4.815.185
6.535.965
6.732.044
6.862.763
6.993.483
1.987.195
2.046.811
2.086.555
2.126.299
3.376.680
3.477.980
3.545.513
3.613.047
3.991.715
4.111.466
4.191.300
4.271.135
3.634.284
3.743.312
3.815.998
3.888.684
5.979.623
6.159.012
6.278.604
6.398.197
7.486.624
7.711.223
7.860.956
8.010.688
3.719.795
3.831.389
3.905.785
3.980.181
4.494.815
4.629.659
4.719.555
4.809.452
5.554.365
5.720.996
5.832.083
5.943.170
2.411.914
2.484.271
2.532.510
2.580.748
G-4-16-ii
3.607.039
3.715.250
3.787.391
3.859.532
183
G-4-16-iii
6.546.132
6.742.516
6.873.438
7.004.361
184
G-4-17-i
3.446.846
3.550.251
3.619.188
3.688.125
185
G-4-17-ii
4.277.687
4.406.018
4.491.571
4.577.125
186
G-4-17-iii
7.169.439
7.384.522
7.527.911
7.671.299
187
G-4-18-i
2.894.297
2.981.126
3.039.012
3.096.897
188
G-4-18-ii
4.149.921
4.274.418
4.357.417
4.440.415
189
G-4-18-iii
4.396.418
4.528.311
4.616.239
4.704.167
190
G-4-19-i
2.411.914
2.484.271
2.532.510
2.580.748
191
G-4-19-ii
4.888.068
5.034.710
5.132.471
5.230.233
192
G-4-19-iii
7.291.446
7.510.189
7.656.018
7.801.847
193
G-4-20-i
1.688.340
1.738.990
1.772.757
1.806.524

BELAKANG SEDANG
BELAKANG BERAT
DEGENERATIF RINGAN
DEGENERATIF SEDANG
DEGENERATIF BERAT
RINGAN
SEDANG
BERAT
TRAUMATIK RINGAN
TRAUMATIK SEDANG
TRAUMATIK BERAT
DENGAN INFARK BERAT
TANPA INFARK RINGAN
TANPA INFARK SEDANG
TANPA INFARK BERAT

PERIFER RINGAN
PERIFER SEDANG
PERIFER BERAT
PERSARAFAN RINGAN
PERSARAFAN SEDANG
PERSARAFAN BERAT
(TIDAK TERMASUK MENINGITIS VIRUS) SEDANG
- 112 No
Kode
INA-CBG
194
G-4-20-ii
195
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.397.444
2.469.368
2.517.317
2.565.265
G-4-20-iii
4.088.204
4.210.850
4.292.614
4.374.378
196
G-4-21-i
1.956.400
2.015.092
2.054.220
2.093.348
197
G-4-21-ii
4.051.899
4.173.456
4.254.494
4.335.532
198
G-4-21-iii
4.773.615
4.916.824
5.012.296
5.107.768
199
G-4-22-i
1.929.531
1.987.417
2.026.008
2.064.598
200
G-4-22-ii
2.411.914
2.484.271
2.532.510
2.580.748
201
G-4-22-iii
2.767.096
2.850.109
2.905.451
2.960.793
202
G-4-23-i
1.929.531
1.987.417
2.026.008
2.064.598
203
G-4-23-ii
2.411.914
2.484.271
2.532.510
2.580.748
204
G-4-23-iii
3.447.660
3.551.090
3.620.043
3.688.996
205
G-4-24-i
1.929.531
1.987.417
2.026.008
2.064.598
206
G-4-24-ii
2.411.914
2.484.271
2.532.510
2.580.748
207
G-4-24-iii
TRAUMA KEPALA BERAT
5.068.376
5.220.427
5.321.795
5.423.162
208
G-4-25-i
GEGAR OTAK RINGAN
1.833.431
1.888.434
1.925.103
1.961.772
209
G-4-25-ii
GEGAR OTAK SEDANG
2.308.330
2.377.580
2.423.747
2.469.913
210
G-4-25-iii
GEGAR OTAK BERAT
3.011.733
3.102.085
3.162.319
3.222.554
2.894.297
2.981.126
3.039.012
3.096.897
3.376.680
3.477.980
3.545.513
3.613.047
6.445.609
6.638.977
6.767.889
6.896.801

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
211
G-4-26-i
212
G-4-26-ii
213
G-4-26-iii
214
H-1-20-i
4.858.448
5.004.201
5.101.370
5.198.539
215
H-1-20-ii
8.859.929
9.125.727
9.302.926
9.480.124
216
H-1-20-iii
12.048.950
12.410.419
12.651.398
12.892.377
4.756.883
4.899.590
4.994.727
5.089.865
5.422.847
5.585.532
5.693.989
5.802.446

RINGAN
SEDANG
217
H-1-30-i
218
H-1-30-ii
219
H-1-30-iii
9.047.824
9.319.258
9.500.215
9.681.171
220
H-4-10-i
5.620.764
5.789.387
5.901.802
6.014.217
221
H-4-10-ii
9.367.940
9.648.978
9.836.337
10.023.696
222
H-4-10-iii
15.272.509
15.730.684
16.036.134
16.341.584
223
H-4-11-i
3.747.176
3.859.591
3.934.535
4.009.478
224
H-4-11-ii
4.276.240
4.404.527
4.490.052
4.575.576
225
H-4-11-iii
6.114.623
6.298.061
6.420.354
6.542.646
226
H-4-12-i
4.789.732
4.933.424
5.029.218
5.125.013
227
H-4-12-ii
6.488.005
6.682.645
6.812.405
6.942.165
- 113 No
Kode
INA-CBG
228
H-4-12-iii
Deskripsi (INA-CBG)
JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
KATETERISASI RINGAN
KATETERISASI SEDANG
KATETERISASI BERAT
RINGAN
SEDANG
BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
10.824.794
11.149.538
11.366.033
11.582.529
41.627.323
42.876.143
43.708.689
44.541.235
42.543.341
43.819.641
44.670.508
45.521.375
67.153.848
69.168.463
70.511.540
71.854.617
23.094.599
23.787.437
24.249.329
24.711.221
29.792.033
30.685.794
31.281.634
31.877.475
36.720.412
37.822.025
38.556.433
39.290.841
14.222.476
14.649.150
14.933.599
15.218.049
19.494.351
20.079.182
20.469.069
20.858.956
28.591.715
29.449.467
30.021.301
30.593.135
17.351.004
17.871.534
18.218.554
18.565.574
22.287.672
22.956.302
23.402.056
23.847.809
47.512.689
48.938.070
49.888.324
50.838.578
30.566.381
31.483.372
32.094.700
32.706.028
36.679.657
37.780.047
38.513.640
39.247.233
50.470.977
51.985.106
52.994.526
54.003.945
229
I-1-01-i
230
I-1-01-ii
231
I-1-01-iii
232
I-1-02-i
233
I-1-02-ii
234
I-1-02-iii
235
I-1-03-i
236
I-1-03-ii
237
I-1-03-iii
238
I-1-04-i
239
I-1-04-ii
240
I-1-04-iii
241
I-1-05-i
242
I-1-05-ii
243
I-1-05-iii
244
I-1-06-i
14.408.314
14.840.563
15.128.730
15.416.896
245
I-1-06-ii
21.745.566
22.397.933
22.832.844
23.267.756
246
I-1-06-iii
27.994.318
28.834.147
29.394.034
29.953.920
247
I-1-07-i
18.948.024
19.516.465
19.895.425
20.274.386
248
I-1-07-ii
23.376.237
24.077.524
24.545.049
25.012.573
249
I-1-07-iii
25.503.322
26.268.422
26.778.488
27.288.555
250
I-1-11-i
3.604.376
3.712.507
3.784.595
3.856.683
251
I-1-11-ii
4.007.706
4.127.937
4.208.091
4.288.245
252
I-1-11-iii
5.333.035
5.493.026
5.599.687
5.706.347
253
I-1-12-i
11.046.799
11.378.203
11.599.139
11.820.075
254
I-1-12-ii
15.327.949
15.787.788
16.094.347
16.400.906
255
I-1-12-iii
21.378.871
22.020.237
22.447.815
22.875.392
256
I-1-13-i
6.498.117
6.693.061
6.823.023
6.952.985

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEK RINGAN
- 114 No
Kode
INA-CBG
257
I-1-13-ii
258
I-1-13-iii
259
I-1-14-i
260
I-1-14-ii
261
I-1-14-iii
262
I-1-15-i
263
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
7.560.161
7.786.966
7.938.169
8.089.372
13.781.668
14.195.118
14.470.751
14.746.385
23.773.852
24.487.067
24.962.544
25.438.021
29.547.502
30.433.927
31.024.877
31.615.827
38.717.416
39.878.938
40.653.287
41.427.635
4.658.535
4.798.291
4.891.462
4.984.632
I-1-15-ii
13.646.046
14.055.427
14.328.348
14.601.269
264
I-1-15-iii
70.633.971
72.752.990
74.165.669
75.578.349
265
I-1-16-i
10.188.794
10.494.457
10.698.233
10.902.009
266
I-1-16-ii
26.490.863
27.285.589
27.815.407
28.345.224
267
I-1-16-iii
30.556.561
31.473.258
32.084.389
32.695.520
268
I-1-17-i
3.267.628
3.365.657
3.431.009
3.496.362
269
I-1-17-ii
6.768.442
6.971.496
7.106.864
7.242.233
270
I-1-17-iii
39.239.311
40.416.491
41.201.277
41.986.063
271
I-1-20-i
3.898.870
4.015.836
4.093.814
4.171.791
272
I-1-20-ii
7.017.966
7.228.505
7.368.864
7.509.224
273
I-1-20-iii
9.357.289
9.638.007
9.825.153
10.012.299
274
I-1-30-i
11.559.239
11.906.017
12.137.201
12.368.386
275
I-1-30-ii
24.045.553
24.766.920
25.247.831
25.728.742
276
I-1-30-iii
37.261.874
38.379.730
39.124.968
39.870.205
277
I-1-40-i
15.544.571
16.010.908
16.321.800
16.632.691
278
I-1-40-ii
21.588.070
22.235.712
22.667.474
23.099.235
279
I-1-40-iii
27.050.842
27.862.367
28.403.384
28.944.401
280
I-4-10-i
4.520.813
4.656.437
4.746.854
4.837.270
281
I-4-10-ii
7.138.445
7.352.598
7.495.367
7.638.136
282
I-4-10-iii
10.297.829
10.606.764
10.812.721
11.018.677
283
I-4-11-i
5.360.502
5.521.317
5.628.527
5.735.737
284
I-4-11-ii
6.633.642
6.832.651
6.965.324
7.097.997
285
I-4-11-iii
11.739.972
12.092.171
12.326.970
12.561.770

KOMPLEK SEDANG
KOMPLEK BERAT

DARAH VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
- 115 No
Kode
INA-CBG
286
I-4-12-i
287
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.695.243
4.836.100
4.930.005
5.023.909
I-4-12-ii
6.700.098
6.901.101
7.035.103
7.169.105
288
I-4-12-iii
8.128.161
8.372.006
8.534.569
8.697.132
289
I-4-13-i
4.217.618
4.344.147
4.428.499
4.512.852
290
I-4-13-ii
6.127.339
6.311.159
6.433.706
6.556.253
291
I-4-13-iii
12.541.952
12.918.211
13.169.050
13.419.889
292
I-4-14-i
2.622.969
2.701.658
2.754.118
2.806.577
293
I-4-14-ii
3.069.262
3.161.340
3.222.725
3.284.110
294
I-4-14-iii
4.756.335
4.899.025
4.994.151
5.089.278
295
I-4-15-i
3.859.062
3.974.834
4.052.015
4.129.197
296
I-4-15-ii
5.524.439
5.690.172
5.800.661
5.911.149
297
I-4-15-iii
6.296.531
6.485.427
6.611.358
6.737.288
298
I-4-16-i
2.894.297
2.981.126
3.039.012
3.096.897
299
I-4-16-ii
4.690.658
4.831.378
4.925.191
5.019.004
300
I-4-16-iii
5.909.396
6.086.678
6.204.866
6.323.054
301
I-4-17-i
HIPERTENSI RINGAN
2.590.336
2.668.046
2.719.852
2.771.659
302
I-4-17-ii
HIPERTENSI SEDANG
3.668.173
3.778.218
3.851.582
3.924.945
303
I-4-17-iii
HIPERTENSI BERAT
4.462.508
4.596.383
4.685.633
4.774.883
304
I-4-18-i
3.814.820
3.929.265
4.005.561
4.081.858
305
I-4-18-ii
5.844.049
6.019.371
6.136.252
6.253.133
306
I-4-18-iii
7.878.715
8.115.077
8.272.651
8.430.225
307
I-4-19-i
2.985.597
3.075.165
3.134.877
3.194.589
308
I-4-19-ii
4.890.314
5.037.024
5.134.830
5.232.636
309
I-4-19-iii
5.829.210
6.004.086
6.120.671
6.237.255
310
I-4-20-i
3.623.445
3.732.148
3.804.617
3.877.086
311
I-4-20-ii
4.174.479
4.299.713
4.383.203
4.466.693
312
I-4-20-iii
5.540.228
5.706.435
5.817.240
5.928.044
313
I-4-21-i
4.818.595
4.963.153
5.059.525
5.155.897
314
I-4-21-ii
6.010.885
6.191.211
6.311.429
6.431.647
315
I-4-21-iii
8.200.121
8.446.125
8.610.127
8.774.130
316
I-4-22-i
3.135.488
3.229.553
3.292.263
3.354.972
317
I-4-22-ii
3.613.021
3.721.411
3.793.672
3.865.932
318
I-4-22-iii
5.271.299
5.429.438
5.534.864
5.640.290

VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT


RINGAN
SEDANG
KONGENITAL BERAT
RINGAN
SEDANG
BERAT
- 116 No
Kode
INA-CBG
319
I-4-23-i
320
I-4-23-ii
321
I-4-23-iii
322
I-4-24-i
323
I-4-24-ii
324
I-4-24-iii
325
J-1-01-i
326
J-1-01-ii
327
J-1-01-iii
328
J-1-02-i
329
J-1-02-ii
330
J-1-02-iii
331
J-1-10-i
332
J-1-10-ii
333
J-1-10-iii
334
J-1-20-i
335
J-1-20-ii
336
J-1-20-iii
337
J-1-30-i
338
J-1-30-ii
339
J-1-30-iii
340
J-4-10-i
341
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.375.309
2.446.568
2.494.075
2.541.581
2.916.332
3.003.822
3.062.149
3.120.475
5.698.247
5.869.195
5.983.160
6.097.125
2.833.058
2.918.050
2.974.711
3.031.372
7.073.362
7.285.562
7.427.030
7.568.497
8.942.988
9.211.278
9.390.137
9.568.997
23.266.717
23.964.719
24.430.053
24.895.388
25.342.657
26.102.936
26.609.789
27.116.642
41.660.116
42.909.919
43.743.121
44.576.324
11.667.726
12.017.758
12.251.113
12.484.467
12.499.244
12.874.221
13.124.206
13.374.191
18.470.321
19.024.430
19.393.837
19.763.243
4.552.916
4.689.503
4.780.561
4.871.620
10.996.946
11.326.854
11.546.793
11.766.732
19.471.444
20.055.587
20.445.016
20.834.445
3.935.176
4.053.231
4.131.935
4.210.638
5.723.403
5.895.105
6.009.573
6.124.041
8.606.230
8.864.417
9.036.541
9.208.666
2.653.706
2.733.318
2.786.392
2.839.466
12.996.234
13.386.121
13.646.046
13.905.971
39.196.071
40.371.954
41.155.875
41.939.796
3.062.731
3.154.613
3.215.868
3.277.123
J-4-10-ii
4.379.338
4.510.718
4.598.305
4.685.892
342
J-4-10-iii
6.625.285
6.824.043
6.956.549
7.089.055
343
J-4-11-i
1.932.194
1.990.160
2.028.804
2.067.447
344
J-4-11-ii
2.689.570
2.770.257
2.824.048
2.877.840
345
J-4-11-iii
3.854.222
3.969.849
4.046.933
4.124.018
346
J-4-12-i
EMBOLI PARU RINGAN
2.954.826
3.043.471
3.102.568
3.161.664
347
J-4-12-ii
EMBOLI PARU SEDANG
3.826.399
3.941.191
4.017.719
4.094.247
348
J-4-12-iii
EMBOLI PARU BERAT
5.109.769
5.263.062
5.365.258
5.467.453
349
J-4-13-i
4.551.554
4.688.101
4.779.132
4.870.163

RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
- 117 No
Kode
INA-CBG
350
J-4-13-ii
351
J-4-13-iii
352
J-4-14-i
353
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
6.690.785
6.891.509
7.025.324
7.159.140
10.878.215
11.204.562
11.422.126
11.639.690
TUMOR PARU RINGAN
3.101.741
3.194.793
3.256.828
3.318.862
J-4-14-ii
TUMOR PARU SEDANG
5.195.840
5.351.715
5.455.632
5.559.549
354
J-4-14-iii
TUMOR PARU BERAT
6.177.590
6.362.917
6.486.469
6.610.021
355
J-4-15-i
2.894.297
2.981.126
3.039.012
3.096.897
356
J-4-15-ii
5.237.654
5.394.783
5.499.537
5.604.290
357
J-4-15-iii
6.544.344
6.740.674
6.871.561
7.002.448
358
J-4-16-i
2.411.914
2.484.271
2.532.510
2.580.748
359
J-4-16-ii
3.376.680
3.477.980
3.545.513
3.613.047
360
J-4-16-iii
6.091.175
6.273.910
6.395.733
6.517.557
361
J-4-17-i
3.012.107
3.102.471
3.162.713
3.222.955
362
J-4-17-ii
4.069.875
4.191.971
4.273.369
4.354.766
363
J-4-17-iii
5.320.998
5.480.628
5.587.048
5.693.468
364
J-4-18-i
2.710.044
2.791.346
2.845.547
2.899.747
365
J-4-18-ii
3.773.467
3.886.671
3.962.140
4.037.610
366
J-4-18-iii
3.913.919
4.031.337
4.109.615
4.187.894
367
J-4-19-i
3.376.680
3.477.980
3.545.513
3.613.047
368
J-4-19-ii
3.859.062
3.974.834
4.052.015
4.129.197
369
J-4-19-iii
6.045.674
6.227.044
6.347.957
6.468.871
370
J-4-20-i
3.376.680
3.477.980
3.545.513
3.613.047
371
J-4-20-ii
4.118.925
4.242.493
4.324.871
4.407.250
372
J-4-20-iii
9.307.285
9.586.504
9.772.650
9.958.795
373
J-4-21-i
1.929.531
1.987.417
2.026.008
2.064.598
374
J-4-21-ii
4.760.506
4.903.321
4.998.531
5.093.741
375
J-4-21-iii
6.790.038
6.993.739
7.129.540
7.265.341
376
K-1-10-i
5.198.494
5.354.448
5.458.418
5.562.388
377
K-1-10-ii
7.254.839
7.472.485
7.617.581
7.762.678
378
K-1-10-iii
8.496.666
8.751.566
8.921.499
9.091.433
379
K-1-11-i
4.469.905
4.604.002
4.693.400
4.782.798
380
K-1-11-ii
5.868.446
6.044.499
6.161.868
6.279.237
381
K-1-11-iii
14.892.960
15.339.749
15.637.608
15.935.468
K-1-12-i

2.404.467
2.476.601
2.524.690
2.572.779
382

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT

USUS BESAR (RINGAN)
USUS BESAR (SEDANG)
USUS BESAR (BERAT)
- 118 No
Kode
INA-CBG
383
K-1-12-ii
384
K-1-12-iii
385
K-1-13-i
386
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.133.764
3.227.777
3.290.452
3.353.127
6.233.715
6.420.727
6.545.401
6.670.076
2.731.145
2.813.079
2.867.702
2.922.325
K-1-13-ii
4.770.525
4.913.641
5.009.052
5.104.462
387
K-1-13-iii
5.101.905
5.254.962
5.357.000
5.459.038
388
K-1-14-i
4.413.691
4.546.102
4.634.376
4.722.650
389
K-1-14-ii
5.184.381
5.339.912
5.443.600
5.547.287
390
K-1-14-iii
12.765.448
13.148.412
13.403.721
13.659.030
391
K-1-20-i
8.563.856
8.820.772
8.992.049
9.163.326
392
K-1-20-ii
11.952.885
12.311.471
12.550.529
12.789.587
393
K-1-20-iii
25.531.926
26.297.884
26.808.523
27.319.161
394
K-1-30-i
5.637.156
5.806.271
5.919.014
6.031.757
395
K-1-30-ii
10.396.987
10.708.897
10.916.837
11.124.776
396
K-1-30-iii
16.191.974
16.677.733
17.001.573
17.325.412
397
K-1-40-i
5.663.204
5.833.100
5.946.364
6.059.628
398
K-1-40-ii
6.231.794
6.418.747
6.543.383
6.668.019
399
K-1-40-iii
10.334.830
10.644.874
10.851.571
11.058.268
400
K-1-50-i
4.319.658
4.449.248
4.535.641
4.622.034
401
K-1-50-ii
5.594.161
5.761.986
5.873.869
5.985.753
402
K-1-50-iii
PROSEDUR ANAL BERAT
7.942.221
8.180.488
8.339.332
8.498.177
403
K-4-10-i
3.271.830
3.369.985
3.435.422
3.500.859
404
K-4-10-ii
3.914.937
4.032.385
4.110.684
4.188.983
405
K-4-10-iii
16.211.704
16.698.056
17.022.290
17.346.524
406
K-4-11-i
1.929.531
1.987.417
2.026.008
2.064.598
407
K-4-11-ii
2.894.297
2.981.126
3.039.012
3.096.897
408
K-4-11-iii
5.259.980
5.417.779
5.522.979
5.628.179
409
K-4-12-i
1.929.531
1.987.417
2.026.008
2.064.598
410
K-4-12-ii
2.882.690
2.969.170
3.026.824
3.084.478
411
K-4-12-iii
6.918.250
7.125.797
7.264.162
7.402.527
412
K-4-13-i
2.894.297
2.981.126
3.039.012
3.096.897
413
K-4-13-ii
3.748.827
3.861.292
3.936.268
4.011.245
414
K-4-13-iii
6.131.440
6.315.383
6.438.012
6.560.641


RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)

(RINGAN)
(SEDANG)
- 119 No
Kode
INA-CBG
415
K-4-14-i
416
K-4-14-ii
417
K-4-14-iii
418
K-4-15-i
419
K-4-15-ii
420
K-4-15-iii
421
K-4-16-i
422
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.411.914
2.484.271
2.532.510
2.580.748
3.264.274
3.362.202
3.427.487
3.492.773
4.937.525
5.085.651
5.184.402
5.283.152
2.411.914
2.484.271
2.532.510
2.580.748
4.535.056
4.671.108
4.761.809
4.852.510
6.452.568
6.646.146
6.775.197
6.904.248
2.411.914
2.484.271
2.532.510
2.580.748
K-4-16-ii
2.894.297
2.981.126
3.039.012
3.096.897
423
K-4-16-iii
3.532.865
3.638.851
3.709.508
3.780.166
424
K-4-17-i
1.929.531
1.987.417
2.026.008
2.064.598
425
K-4-17-ii
2.815.222
2.899.679
2.955.983
3.012.288
426
K-4-17-iii
3.746.773
3.859.176
3.934.112
4.009.047
427
K-4-18-i
1.929.531
1.987.417
2.026.008
2.064.598
428
K-4-18-ii
2.995.433
3.085.296
3.145.204
3.205.113
429
K-4-18-iii
3.543.582
3.649.889
3.720.761
3.791.633
430
L-1-20-i
19.745.377
20.337.739
20.732.646
21.127.554
431
L-1-20-ii
20.540.636
21.156.855
21.567.667
21.978.480
432
L-1-20-iii
31.470.625
32.414.744
33.044.156
33.673.569
433
L-1-30-i
8.955.922
9.224.599
9.403.718
9.582.836
434
L-1-30-ii
12.972.682
13.361.862
13.621.316
13.880.769
435
L-1-30-iii
13.682.131
14.092.595
14.366.238
14.639.881
436
L-1-40-i
3.616.141
3.724.625
3.796.948
3.869.270
437
L-1-40-ii
8.138.847
8.383.013
8.545.790
8.708.567
438
L-1-40-iii
13.793.195
14.206.991
14.482.855
14.758.719
439
L-1-50-i
6.498.117
6.693.061
6.823.023
6.952.985
440
L-1-50-ii
11.696.611
12.047.509
12.281.441
12.515.373
441
L-1-50-iii
14.142.857
14.567.143
14.850.000
15.132.857
442
L-4-10-i
2.894.297
2.981.126
3.039.012
3.096.897
443
L-4-10-ii
3.376.680
3.477.980
3.545.513
3.613.047
444
L-4-10-iii
6.830.734
7.035.656
7.172.271
7.308.885
445
L-4-11-i
2.737.478
2.819.602
2.874.351
2.929.101
446
L-4-11-ii
3.750.296
3.862.805
3.937.811
4.012.817

RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
- 120 No
Kode
INA-CBG
447
L-4-11-iii
448
L-4-12-i
449
L-4-12-ii
450
L-4-12-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
10.170.335
10.475.445
10.678.852
10.882.258
2.894.297
2.981.126
3.039.012
3.096.897
4.246.605
4.374.003
4.458.935
4.543.867
7.121.054
7.334.685
7.477.106
7.619.528
1.816.663
1.871.163
1.907.496
1.943.829
2.094.719
2.157.561
2.199.455
2.241.350
3.142.242
3.236.509
3.299.354
3.362.199
1.929.531
1.987.417
2.026.008
2.064.598
2.894.297
2.981.126
3.039.012
3.096.897
4.525.285
4.661.044
4.751.549
4.842.055
9.407.216
9.689.433
9.877.577
10.065.721
10.499.975
10.814.974
11.024.974
11.234.973
14.749.620
15.192.109
15.487.101
15.782.094

451
L-4-13-i
452
L-4-13-ii
453
L-4-13-iii
454
L-4-14-i
455
L-4-14-ii
456
L-4-14-iii
457
M-1-01-i
458
M-1-01-ii
459
M-1-01-iii
460
M-1-02-i
6.662.708
6.862.590
6.995.844
7.129.098
461
M-1-02-ii
10.938.900
11.267.067
11.485.845
11.704.623
462
M-1-02-iii
19.809.847
20.404.142
20.800.339
21.196.536
463
M-1-03-i
16.895.104
17.401.957
17.739.860
18.077.762
464
M-1-03-ii
19.772.213
20.365.379
20.760.824
21.156.268
465
M-1-03-iii
20.144.163
20.748.488
21.151.371
21.554.254
466
M-1-04-i
4.395.189
4.527.045
4.614.948
4.702.852
467
M-1-04-ii
5.634.587
5.803.624
5.916.316
6.029.008
468
M-1-04-iii
7.050.623
7.262.142
7.403.154
7.544.167
469
M-1-05-i
6.846.860
7.052.266
7.189.203
7.326.141
470
M-1-05-ii
7.913.136
8.150.530
8.308.793
8.467.055
471
M-1-05-iii
13.478.226
13.882.572
14.152.137
14.421.701
472
M-1-07-i
7.557.975
7.784.715
7.935.874
8.087.034
473
M-1-07-ii
10.125.325
10.429.085
10.631.592
10.834.098
474
M-1-07-iii
20.626.248
21.245.035
21.657.560
22.070.085
475
M-1-10-i
4.723.589
4.865.297
4.959.769
5.054.241
476
M-1-10-ii
17.545.994
18.072.374
18.423.294
18.774.214
477
M-1-10-iii
21.462.095
22.105.958
22.535.200
22.964.442
478
M-1-20-i
4.672.850
4.813.036
4.906.493
4.999.950

TULANG WAJAH RINGAN
TULANG WAJAH SEDANG
TULANG WAJAH BERAT
SENDI MAYOR RINGAN
- 121 No
Kode
INA-CBG
479
M-1-20-ii
480
M-1-20-iii
481
M-1-30-i
482
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
6.670.074
6.870.177
7.003.578
7.136.980
12.965.171
13.354.126
13.613.429
13.872.733
2.795.063
2.878.915
2.934.816
2.990.717
M-1-30-ii
5.775.311
5.948.571
6.064.077
6.179.583
483
M-1-30-iii
PROSEDUR KAKI BERAT
8.615.547
8.874.013
9.046.324
9.218.635
484
M-1-40-i
2.824.194
2.908.920
2.965.404
3.021.888
485
M-1-40-ii
5.198.494
5.354.448
5.458.418
5.562.388
486
M-1-40-iii
9.097.364
9.370.285
9.552.232
9.734.179
487
M-1-50-i
3.740.289
3.852.498
3.927.304
4.002.109
488
M-1-50-ii
7.529.290
7.755.169
7.905.754
8.056.340
489
M-1-50-iii
10.396.987
10.708.897
10.916.837
11.124.776
2.822.738
2.907.420
2.963.875
3.020.330
5.651.140
5.820.674
5.933.697
6.046.720
9.834.982
10.130.032
10.326.732
10.523.431
3.781.334
3.894.774
3.970.401
4.046.027
7.715.794
7.947.268
8.101.584
8.255.900
12.438.792
12.811.956
13.060.732
13.309.508

SENDI MAYOR SEDANG
SENDI MAYOR BERAT

RINGAN
SEDANG
BERAT

SELAIN KAKI (BERAT)
490
M-1-60-i
491
M-1-60-ii
492
M-1-60-iii
493
M-1-70-i
494
M-1-70-ii
495
M-1-70-iii
496
M-1-80-i
3.046.732
3.138.134
3.199.068
3.260.003
497
M-1-80-ii
4.606.036
4.744.217
4.836.337
4.928.458
498
M-1-80-iii
10.604.287
10.922.416
11.134.501
11.346.587
499
M-4-10-i
1.929.531
1.987.417
2.026.008
2.064.598
500
M-4-10-ii
2.943.980
3.032.299
3.091.179
3.150.059
501
M-4-10-iii
FRAKTUR FEMUR BERAT
6.251.386
6.438.927
6.563.955
6.688.983
502
M-4-11-i
2.553.636
2.630.245
2.681.318
2.732.391
503
M-4-11-ii
5.858.422
6.034.175
6.151.343
6.268.512
504
M-4-11-iii
10.398.562
10.710.519
10.918.490
11.126.461
505
M-4-12-i
1.929.531
1.987.417
2.026.008
2.064.598
506
M-4-12-ii
3.510.780
3.616.103
3.686.319
3.756.534
507
M-4-12-iii
7.031.173
7.242.108
7.382.732
7.523.355
508
M-4-13-i
3.562.085
3.668.947
3.740.189
3.811.431
509
M-4-13-ii
4.823.828
4.968.543
5.065.019
5.161.496

PANGGUL RINGAN
PANGGUL SEDANG
PANGGUL BERAT
PELVIS RINGAN
PELVIS SEDANG
PELVIS BERAT
- 122 No
Kode
INA-CBG
510
M-4-13-iii
511
M-4-14-i
512
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
10.596.310
10.914.199
11.126.126
11.338.052
3.859.062
3.974.834
4.052.015
4.129.197
M-4-14-ii
5.010.098
5.160.401
5.260.602
5.360.804
513
M-4-14-iii
OSTEOMIELITIS BERAT
7.504.586
7.729.724
7.879.815
8.029.907
514
M-4-15-i
2.407.642
2.479.871
2.528.024
2.576.177
515
M-4-15-ii
3.210.392
3.306.704
3.370.912
3.435.120
516
M-4-15-iii
8.200.507
8.446.523
8.610.533
8.774.543
517
M-4-16-i
2.411.914
2.484.271
2.532.510
2.580.748
518
M-4-16-ii
3.859.062
3.974.834
4.052.015
4.129.197
519
M-4-16-iii
7.175.650
7.390.920
7.534.433
7.677.946
2.411.914
2.484.271
2.532.510
2.580.748
3.376.680
3.477.980
3.545.513
3.613.047
4.715.712
4.857.184
4.951.498
5.045.812
2.827.138
2.911.952
2.968.495
3.025.037
3.859.062
3.974.834
4.052.015
4.129.197
4.794.661
4.938.500
5.034.394
5.130.287
2.102.015
2.165.076
2.207.116
2.249.156
3.540.467
3.646.681
3.717.490
3.788.299
6.914.793
7.122.237
7.260.533
7.398.829
1.929.531
1.987.417
2.026.008
2.064.598
2.894.297
2.981.126
3.039.012
3.096.897
3.207.563
3.303.790
3.367.941
3.432.092
1.929.531
1.987.417
2.026.008
2.064.598
2.518.523
2.594.079
2.644.450
2.694.820
6.139.097
6.323.270
6.446.052
6.568.834

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
RINGAN
SEDANG
BERAT
ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
520
M-4-17-i
521
M-4-17-ii
522
M-4-17-iii
523
M-4-18-i
524
M-4-18-ii
525
M-4-18-iii
526
M-4-19-i
527
M-4-19-ii
528
M-4-19-iii
529
M-4-20-i
530
M-4-20-ii
531
M-4-20-iii
532
M-4-21-i
533
M-4-21-ii
534
M-4-21-iii
535
N-1-01-i
5.220.789
5.377.413
5.481.829
5.586.245
536
N-1-01-ii
7.061.000
7.272.830
7.414.050
7.555.270
537
N-1-01-iii
14.971.420
15.420.563
15.719.991
16.019.419
538
N-1-11-i
7.202.482
7.418.556
7.562.606
7.706.656
539
N-1-11-ii
9.741.194
10.033.430
10.228.254
10.423.078
540
N-1-11-iii
20.654.230
21.273.857
21.686.941
22.100.026

RINGAN
SEDANG
- 123 No
Kode
INA-CBG
541
N-1-12-i
542
N-1-12-ii
543
N-1-12-iii
544
N-1-20-i
545
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.898.870
4.015.836
4.093.814
4.171.791
9.070.446
9.342.559
9.523.968
9.705.377
16.531.452
17.027.396
17.358.025
17.688.654
5.278.762
5.437.125
5.542.700
5.648.276
N-1-20-ii
10.465.909
10.779.886
10.989.205
11.198.523
546
N-1-20-iii
11.972.051
12.331.213
12.570.654
12.810.095
547
N-1-30-i
6.280.020
6.468.420
6.594.020
6.719.621
548
N-1-30-ii
9.543.273
9.829.571
10.020.437
10.211.302
549
N-1-30-iii
10.985.881
11.315.457
11.535.175
11.754.892
550
N-1-40-i
5.658.912
5.828.680
5.941.858
6.055.036
551
N-1-40-ii
7.670.857
7.900.983
8.054.400
8.207.817
552
N-1-40-iii
8.921.429
9.189.072
9.367.500
9.545.929
553
N-4-10-i
2.411.914
2.484.271
2.532.510
2.580.748
554
N-4-10-ii
3.229.620
3.326.509
3.391.101
3.455.694
555
N-4-10-iii
7.069.057
7.281.129
7.422.510
7.563.891
556
N-4-11-i
1.847.051
1.902.463
1.939.404
1.976.345
557
N-4-11-ii
3.121.472
3.215.116
3.277.546
3.339.975
558
N-4-11-iii
3.617.871
3.726.407
3.798.764
3.871.122
559
N-4-12-i
1.929.531
1.987.417
2.026.008
2.064.598
560
N-4-12-ii
2.894.297
2.981.126
3.039.012
3.096.897
561
N-4-12-iii
4.805.484
4.949.648
5.045.758
5.141.868
562
N-4-13-i
BATU URIN RINGAN
2.545.645
2.622.014
2.672.927
2.723.840
563
N-4-13-ii
BATU URIN SEDANG
3.069.090
3.161.163
3.222.545
3.283.927
564
N-4-13-iii
BATU URIN BERAT
7.558.327
7.785.077
7.936.244
8.087.410
1.671.332
1.721.472
1.754.898
1.788.325
2.573.640
2.650.850
2.702.322
2.753.795
4.173.624
4.298.833
4.382.306
4.465.778
2.479.551
2.553.937
2.603.528
2.653.119
3.402.715
3.504.797
3.572.851
3.640.905
565
N-4-14-i
566
N-4-14-ii
567
N-4-14-iii
568
N-4-15-i
569
N-4-15-ii


URIN BAWAH RINGAN
URIN BAWAH SEDANG
URIN BAWAH BERAT
RINGAN
SEDANG
BERAT
GINJAL RINGAN
GINJAL SEDANG
GINJAL BERAT

(RINGAN)
(SEDANG)
(BERAT)
SALURAN URIN RINGAN
SALURAN URIN SEDANG
- 124 No
Kode
INA-CBG
570
N-4-15-iii
571
N-4-16-i
572
N-4-16-ii
573
N-4-16-iii
574
O-6-10-i
575
O-6-10-ii
576
O-6-10-iii
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
584
585
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.883.112
3.999.605
4.077.268
4.154.930
3.218.114
3.314.658
3.379.020
3.443.382
3.859.062
3.974.834
4.052.015
4.129.197
8.115.034
8.358.485
8.520.786
8.683.086
4.751.704
4.894.256
4.989.290
5.084.324
5.275.116
5.433.370
5.538.872
5.644.374
5.913.469
6.090.873
6.209.142
6.327.411
2.483.411
2.557.913
2.607.581
2.657.249
3.185.989
3.281.569
3.345.289
3.409.008
5.399.263
5.561.241
5.669.226
5.777.211
2.162.566
2.227.443
2.270.694
2.313.945
2.597.236
2.675.153
2.727.098
2.779.042
3.263.055
3.360.946
3.426.208
3.491.469
2.167.281
2.232.299
2.275.645
2.318.990
O-6-13-ii
3.194.146
3.289.971
3.353.854
3.417.737
O-6-13-iii
3.774.988
3.888.237
3.963.737
4.039.237
48.481.088
49.935.521
50.905.143
51.874.764
59.987.763
61.787.396
62.987.151
64.186.906
70.408.818
72.521.082
73.929.258
75.337.435
58.738.622
60.500.781
61.675.553
62.850.326
67.379.246
69.400.623
70.748.208
72.095.793
76.985.606
79.295.174
80.834.886
82.374.598
3.249.059
3.346.530
3.411.511
3.476.493
4.548.682
4.685.142
4.776.116
4.867.090
7.165.206
7.380.162
7.523.466
7.666.770
29.016.375
29.886.866
30.467.193
31.047.521
37.656.998
38.786.708
39.539.848
40.292.988
53.990.657
55.610.377
56.690.190
57.770.003
15.778.164
16.251.509
16.567.072
16.882.635
586
P-8-01-i
587
P-8-01-ii
588
P-8-01-iii
589
P-8-02-i
590
P-8-02-ii
591
P-8-02-iii
592
P-8-03-i
593
P-8-03-ii
594
P-8-03-iii
595
P-8-04-i
596
P-8-04-ii
597
P-8-04-iii
598
P-8-05-i

SALURAN URIN BERAT
RINGAN
SEDANG
BERAT
&KURET RINGAN
KURET SEDANG
KURET BERAT

- 125 No
Kode
INA-CBG
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii
603
P-8-06-iii
604
P-8-07-i
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
614
P-8-11-ii
615
P-8-11-iii
616
P-8-12-i
617
P-8-12-ii
618
P-8-12-iii
619
P-8-13-i
620
P-8-13-ii
621
P-8-13-iii
622
P-8-14-i
623
P-8-14-ii
624
P-8-14-iii
625
P-8-15-i
626
P-8-15-ii
Deskripsi (INA-CBG)
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
RINGAN
SEDANG
BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
ASPIRASI RINGAN
ASPIRASI SEDANG
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
22.363.420
23.034.323
23.481.591
23.928.859
32.949.497
33.937.982
34.596.972
35.255.962
2.599.247
2.677.224
2.729.209
2.781.194
6.540.386
6.736.598
6.867.405
6.998.213
12.165.864
12.530.840
12.774.157
13.017.475
4.548.682
4.685.142
4.776.116
4.867.090
12.753.409
13.136.012
13.391.080
13.646.148
16.895.104
17.401.957
17.739.860
18.077.762
3.296.347
3.395.237
3.461.164
3.527.091
4.679.628
4.820.017
4.913.610
5.007.202
6.606.198
6.804.384
6.936.508
7.068.632
2.045.050
2.106.401
2.147.302
2.188.203
2.962.552
3.051.429
3.110.680
3.169.931
5.816.363
5.990.854
6.107.181
6.223.509
5.759.730
5.932.521
6.047.716
6.162.911
12.262.306
12.630.176
12.875.422
13.120.668
12.519.204
12.894.780
13.145.164
13.395.548
2.717.289
2.798.808
2.853.154
2.907.500
4.224.913
4.351.660
4.436.159
4.520.657
4.984.504
5.134.039
5.233.729
5.333.419
1.404.442
1.446.575
1.474.664
1.502.752
2.598.908
2.676.875
2.728.854
2.780.832
3.886.945
4.003.553
4.081.292
4.159.031
2.566.061
2.643.043
2.694.364
2.745.685
5.239.170
5.396.345
5.501.128
5.605.912
5.747.350
5.919.770
6.034.717
6.149.664
1.929.758
1.987.650
2.026.246
2.064.841
3.857.078
3.972.791
4.049.932
4.127.074
- 126 No
Kode
INA-CBG
627
P-8-15-iii
628
P-8-16-i
629
P-8-16-ii
630
P-8-16-iii
631
P-8-17-i
632
P-8-17-ii
633
P-8-17-iii
634
S-4-10-i
635
S-4-10-ii
636
S-4-10-iii
637
S-4-11-i
638
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.530.736
4.666.658
4.757.272
4.847.887
1.746.887
1.799.293
1.834.231
1.869.169
2.478.034
2.552.375
2.601.935
2.651.496
3.216.609
3.313.108
3.377.440
3.441.772
1.152.941
1.187.530
1.210.589
1.233.647
3.829.682
3.944.572
4.021.166
4.097.759
7.729.968
7.961.867
8.116.467
8.271.066
1.929.531
1.987.417
2.026.008
2.064.598
2.411.914
2.484.271
2.532.510
2.580.748
3.135.074
3.229.126
3.291.828
3.354.529
1.205.957
1.242.136
1.266.255
1.290.374
S-4-11-ii
1.835.489
1.890.554
1.927.264
1.963.974
639
S-4-11-iii
2.969.501
3.058.586
3.117.976
3.177.366
640
S-4-12-i
1.447.148
1.490.563
1.519.506
1.548.449
641
S-4-12-ii
1.929.531
1.987.417
2.026.008
2.064.598
642
S-4-12-iii
3.768.527
3.881.583
3.956.953
4.032.324
1.929.531
1.987.417
2.026.008
2.064.598
3.410.978
3.513.308
3.581.527
3.649.747
6.945.186
7.153.541
7.292.445
7.431.349
1.175.628
1.210.897
1.234.409
1.257.922
2.497.428
2.572.351
2.622.299
2.672.248
4.736.013
4.878.093
4.972.814
5.067.534
889.138
915.812
933.595
951.378
1.678.107
1.728.450
1.762.012
1.795.574
2.173.538
2.238.744
2.282.215
2.325.686

ASPIRASI BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT

PASIEN RINGAN
PASIEN SEDANG
PASIEN BERAT
643
S-4-13-i
644
S-4-13-ii
645
S-4-13-iii
646
S-4-14-i
647
S-4-14-ii
648
S-4-14-iii
649
S-4-15-i
650
S-4-15-ii
651
S-4-15-iii
652
S-4-16-i
LUKA BAKAR RINGAN
3.376.680
3.477.980
3.545.513
3.613.047
653
S-4-16-ii
LUKA BAKAR SEDANG
4.768.971
4.912.041
5.007.420
5.102.799
654
S-4-16-iii
LUKA BAKAR BERAT
8.515.739
8.771.211
8.941.526
9.111.841
655
S-4-17-i
1.800.512
1.854.527
1.890.537
1.926.548
656
S-4-17-ii
2.411.914
2.484.271
2.532.510
2.580.748
657
S-4-17-iii
3.933.102
4.051.095
4.129.757
4.208.419
658
T-1-10-i
1.858.625
1.914.384
1.951.556
1.988.729

- 127 No
Kode
INA-CBG
659
T-1-10-ii
660
T-1-10-iii
661
T-4-10-i
662
T-4-10-ii
663
T-4-10-iii
664
T-4-11-i
665
T-4-11-ii
666
T-4-11-iii
667
T-4-12-i
668
T-4-12-ii
669
T-4-12-iii
670
U-1-10-i
671
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.496.007
2.570.888
2.620.808
2.670.728
4.541.051
4.677.282
4.768.103
4.858.924
813.016
837.406
853.666
869.927
1.549.427
1.595.910
1.626.899
1.657.887
2.252.447
2.320.020
2.365.069
2.410.118
804.026
828.147
844.227
860.308
1.265.308
1.303.267
1.328.573
1.353.879
2.038.038
2.099.179
2.139.940
2.180.701
1.688.340
1.738.990
1.772.757
1.806.524
2.551.833
2.628.388
2.679.424
2.730.461
3.969.735
4.088.827
4.168.221
4.247.616
1.797.083
1.850.996
1.886.937
1.922.879
U-1-10-ii
3.667.058
3.777.070
3.850.411
3.923.752
672
U-1-10-iii
15.835.098
16.310.151
16.626.853
16.943.555
673
U-1-11-i
674
U-1-11-ii
675
U-1-11-iii
676

DOKTER RINGAN
DOKTER SEDANG
DOKTER BERAT

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
7.797.740
8.031.673
8.187.627
8.343.582
10.396.987
10.708.897
10.916.837
11.124.776
17.467.864
17.991.900
18.341.257
18.690.615
U-1-12-i
4.765.283
4.908.242
5.003.548
5.098.853
677
U-1-12-ii
11.696.611
12.047.509
12.281.441
12.515.373
678
U-1-12-iii
15.188.270
15.643.919
15.947.684
16.251.449
679
U-1-13-i
5.198.494
5.354.448
5.458.418
5.562.388
680
U-1-13-ii
5.865.311
6.041.271
6.158.577
6.275.883
681
U-1-13-iii
11.309.974
11.649.274
11.875.473
12.101.673
682
U-1-14-i
2.868.365
2.954.416
3.011.784
3.069.151
683
U-1-14-ii
3.520.061
3.625.663
3.696.064
3.766.465
684
U-1-14-iii
4.171.371
4.296.513
4.379.940
4.463.367
685
U-1-15-i
1.684.700
1.735.241
1.768.935
1.802.629
686
U-1-15-ii
2.393.842
2.465.657
2.513.534
2.561.410
687
U-1-15-iii
4.717.161
4.858.676
4.953.019
5.047.362
4.357.586
4.488.314
4.575.465
4.662.617
7.756.503
7.989.198
8.144.328
8.299.458
688
U-1-20-i
689
U-1-20-ii


- 128 No
Kode
INA-CBG
690
U-1-20-iii

691
U-1-30-i
692
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
19.135.576
19.709.643
20.092.355
20.475.066
3.738.049
3.850.190
3.924.951
3.999.712
U-1-30-ii
5.046.366
5.197.757
5.298.684
5.399.612
693
U-1-30-iii
9.892.328
10.189.098
10.386.945
10.584.791
694
U-4-10-i
3.479.499
3.583.884
3.653.474
3.723.064
695
U-4-10-ii
8.722.374
8.984.045
9.158.492
9.332.940
696
U-4-10-iii
12.724.044
13.105.765
13.360.246
13.614.727
697
U-4-11-i
1.929.531
1.987.417
2.026.008
2.064.598
698
U-4-11-ii
2.894.297
2.981.126
3.039.012
3.096.897
699
U-4-11-iii
4.002.801
4.122.885
4.202.941
4.282.997
700
U-4-12-i
1.929.531
1.987.417
2.026.008
2.064.598
701
U-4-12-ii
2.249.389
2.316.871
2.361.858
2.406.846
702
U-4-12-iii
3.576.426
3.683.719
3.755.247
3.826.776
703
U-4-13-i
1.895.622
1.952.491
1.990.403
2.028.316
704
U-4-13-ii
2.203.772
2.269.885
2.313.960
2.358.036
705
U-4-13-iii
2.502.221
2.577.288
2.627.332
2.677.377
706
U-4-14-i
2.411.914
2.484.271
2.532.510
2.580.748
707
U-4-14-ii
2.894.297
2.981.126
3.039.012
3.096.897
708
U-4-14-iii
4.848.449
4.993.903
5.090.872
5.187.841
709
U-4-15-i
1.929.531
1.987.417
2.026.008
2.064.598
710
U-4-15-ii
2.411.914
2.484.271
2.532.510
2.580.748
711
U-4-15-iii
3.377.334
3.478.654
3.546.201
3.613.747
712
V-1-10-i
5.640.659
5.809.879
5.922.692
6.035.505
713
V-1-10-ii
6.498.117
6.693.061
6.823.023
6.952.985
714
V-1-10-iii
12.346.422
12.716.815
12.963.744
13.210.672
715
V-1-11-i
6.498.117
6.693.061
6.823.023
6.952.985
716
V-1-11-ii
7.252.008
7.469.568
7.614.608
7.759.648
717
V-1-11-iii
10.739.113
11.061.286
11.276.069
11.490.851
3.509.506
3.614.791
3.684.981
3.755.171
13.412.165
13.814.530
14.082.773
14.351.016
15.659.924
16.129.722
16.442.921
16.756.119
5.319.273
5.478.851
5.585.237
5.691.622
10.108.145
10.411.390
10.613.553
10.815.716
718
V-1-12-i
719
V-1-12-ii
720
V-1-12-iii
721
V-1-13-i
722
V-1-13-ii

DAN TELINGA RINGAN
DAN TELINGA SEDANG
DAN TELINGA BERAT


KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

- 129 No
Kode
INA-CBG
723
V-1-13-iii
724
V-1-14-i
725
V-1-14-ii
726
V-1-14-iii
727
V-1-15-i
728
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
15.595.481
16.063.345
16.375.255
16.687.165
6.412.446
6.604.819
6.733.068
6.861.317
9.326.353
9.606.143
9.792.670
9.979.197
12.677.820
13.058.154
13.311.711
13.565.267
3.023.111
3.113.804
3.174.267
3.234.729
V-1-15-ii
5.758.438
5.931.191
6.046.360
6.161.529
729
V-1-15-iii
10.123.224
10.426.921
10.629.385
10.831.850
730
V-4-10-i
4.867.972
5.014.011
5.111.371
5.208.730
731
V-4-10-ii
6.287.567
6.476.194
6.601.946
6.727.697
732
V-4-10-iii
12.016.645
12.377.144
12.617.477
12.857.810
733
V-4-11-i
2.475.546
2.549.812
2.599.323
2.648.834
734
V-4-11-ii
3.617.168
3.725.683
3.798.027
3.870.370
735
V-4-11-iii
5.968.088
6.147.131
6.266.493
6.385.854
736
W-1-01-i
7.279.318
7.497.697
7.643.284
7.788.870
737
W-1-01-ii
8.767.593
9.030.621
9.205.973
9.381.324
738
W-1-01-iii
19.365.871
19.946.847
20.334.165
20.721.482
739
W-1-10-i
2.027.281
2.088.100
2.128.645
2.169.191
740
W-1-10-ii
3.783.239
3.896.737
3.972.401
4.048.066
741
W-1-10-iii
6.188.179
6.373.825
6.497.588
6.621.352
742
W-1-11-i
2.105.671
2.168.841
2.210.955
2.253.068
743
W-1-11-ii
4.061.053
4.182.885
4.264.106
4.345.327
744
W-1-11-iii
7.797.740
8.031.673
8.187.627
8.343.582
745
W-1-12-i
1.913.319
1.970.718
2.008.985
2.047.251
746
W-1-12-ii
2.175.407
2.240.669
2.284.177
2.327.685
747
W-1-12-iii
3.341.699
3.441.950
3.508.784
3.575.618
748
W-1-13-i
2.277.301
2.345.620
2.391.166
2.436.712
749
W-1-13-ii
2.472.493
2.546.668
2.596.118
2.645.567
750
W-1-13-iii
3.321.014
3.420.645
3.487.065
3.553.485
751
W-1-20-i
6.204.997
6.391.147
6.515.247
6.639.347
752
W-1-20-ii
8.728.260
8.990.108
9.164.673
9.339.238
753
W-1-20-iii
11.026.252
11.357.040
11.577.565
11.798.090
W-1-30-i

RINGAN
3.387.306
3.488.926
3.556.672
3.624.418
754

NON KOMPLEK (BERAT)

RINGAN
SEDANG
BERAT

SERVIK RINGAN
SERVIK SEDANG
SERVIK BERAT
ENDOSKOP RINGAN
ENDOSKOP SEDANG
ENDOSKOP BERAT
- 130 No
Kode
INA-CBG
755
W-1-30-ii
756
W-1-30-iii
757
W-4-10-i
758
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.402.929
5.565.017
5.673.075
5.781.134
14.367.717
14.798.749
15.086.103
15.373.457
2.526.082
2.601.864
2.652.386
2.702.908
W-4-10-ii
3.414.283
3.516.711
3.584.997
3.653.282
759
W-4-10-iii
7.718.125
7.949.668
8.104.031
8.258.393
760
W-4-11-i
2.411.914
2.484.271
2.532.510
2.580.748
761
W-4-11-ii
3.859.062
3.974.834
4.052.015
4.129.197
762
W-4-11-iii
4.689.904
4.830.602
4.924.400
5.018.198
763
W-4-12-i
1.929.531
1.987.417
2.026.008
2.064.598
764
W-4-12-ii
2.653.105
2.732.698
2.785.761
2.838.823
765
W-4-12-iii
2.957.918
3.046.655
3.105.814
3.164.972
766
W-4-13-i
ABORTUS RINGAN
1.058.178
1.089.923
1.111.087
1.132.250
767
W-4-13-ii
ABORTUS SEDANG
1.447.148
1.490.563
1.519.506
1.548.449
768
W-4-13-iii
ABORTUS BERAT
1.929.531
1.987.417
2.026.008
2.064.598
769
W-4-14-i
1.447.148
1.490.563
1.519.506
1.548.449
770
W-4-14-ii
1.861.266
1.917.104
1.954.330
1.991.555
771
W-4-14-iii
2.342.043
2.412.304
2.459.145
2.505.986
772
W-4-15-i
1.206.753
1.242.956
1.267.091
1.291.226
773
W-4-15-ii
1.342.140
1.382.404
1.409.247
1.436.089
774
W-4-15-iii
1.858.320
1.914.069
1.951.236
1.988.402
775
W-4-16-i
1.447.148
1.490.563
1.519.506
1.548.449
776
W-4-16-ii
1.929.531
1.987.417
2.026.008
2.064.598
777
W-4-16-iii
2.630.653
2.709.573
2.762.186
2.814.799
778
W-4-17-i
1.181.967
1.217.426
1.241.065
1.264.704
779
W-4-17-ii
1.929.531
1.987.417
2.026.008
2.064.598
780
W-4-17-iii
3.650.289
3.759.798
3.832.804
3.905.809
781
Z-4-10-i
REHABILITASI RINGAN
3.310.847
3.410.172
3.476.389
3.542.606
782
Z-4-10-ii
REHABILITASI SEDANG
4.394.671
4.526.512
4.614.405
4.702.298
783
Z-4-10-iii
REHABILITASI BERAT
6.243.050
6.430.341
6.555.202
6.680.063
784
Z-4-11-i
2.890.005
2.976.705
3.034.505
3.092.305
785
Z-4-11-ii
3.478.927
3.583.295
3.652.874
3.722.452
786
Z-4-11-iii
5.504.281
5.669.410
5.779.496
5.889.581
2.810.382
2.894.693
2.950.901
3.007.109
5.726.061
5.897.842
6.012.364
6.126.885
7.276.916
7.495.224
7.640.762
7.786.301
787
Z-4-12-i
788
Z-4-12-ii
789
Z-4-12-iii

SEDANG
BERAT


b. RawatJalan
No
Kode
INA-CBG
B-2-10-0
B-2-11-0
- 131 -
Deskripsi (INA-CBG)
LAPAROSKOPI
PANKREAS
LAPAROSKOPI
EMPEDU
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
800.166
824.171
840.174
856.178
1.037.940
1.069.079
1.089.837
1.110.596
1.930.187
1.988.093
2.026.696
2.065.300
1.595.112
1.642.966
1.674.868
1.706.770
1.332.579
1.372.556
1.399.208
1.425.859
467.208
481.224
490.568
499.913
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
1.041.813
1.073.067
1.093.903
1.114.739
B-3-12-0

214.058
220.480
224.761
229.042
C-3-10-0
583.921
601.438
613.117
624.795
10
C-3-11-0

KEMIH
923.492
951.197
969.667
988.137
11
C-3-12-0
209.354
215.634
219.822
224.009
12
C-3-13-0
203.297
209.396
213.462
217.528
13
C-3-14-0
1.730.670
1.782.590
1.817.203
1.851.817
14
C-3-15-0
1.586.228
1.633.815
1.665.539
1.697.264
15
C-3-16-0
359.718
370.510
377.704
384.899
16
C-3-17-0

LEHER
238.627
245.785
250.558
255.330
17
C-3-18-0
105.797
108.971
111.087
113.202
18
C-3-19-0

MYELOMA ATAU TESTIS
149.618
154.107
157.099
160.091
19
C-3-20-0
2.979.648
3.069.038
3.128.631
3.188.224
20
C-3-21-0
170.741
175.863
179.278
182.693
21
C-3-22-0
749.644
772.133
787.126
802.119
22
C-3-23-0
121.426
125.069
127.497
129.926
23
D-2-10-0

TULANG
1.028.737
1.059.599
1.080.174
1.100.749
24
D-2-11-0
PROSEDUR LIMPA
1.288.155
1.326.799
1.352.563
1.378.326
25
D-2-21-0
1.080.397
1.112.809
1.134.417
1.156.025
26
D-2-22-0
237.115
244.228
248.970
253.713
27
D-3-10-0
171.748
176.900
180.335
183.770
28
D-3-11-0
445.907
459.284
468.203
477.121
29
E-2-10-0
30
E-2-21-0
31
E-2-22-0

OVARIUM
GASTROINTESTINAL
GINJAL ATAU PROSTAT

TYMUS
TYMUS
TULANG
PEMBENTUK DARAH
PARATIROID
THYROGLOSSAL
264.509
272.444
277.734
283.024
191.760
197.513
201.348
205.183
191.760
197.513
201.348
205.183
- 132 No
Kode
INA-CBG
32
E-3-10-0
33
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

ENDOKRIN
223.004
229.694
234.155
238.615
F-3-10-0
TERAPI SHOCK
311.084
320.416
326.638
332.860
34
F-5-10-0
381.178
392.614
400.237
407.861
35
F-5-11-0
TERAPI KELOMPOK
251.352
258.893
263.920
268.947
36
F-5-12-0
321.648
331.297
337.730
344.163
37
F-5-13-0
272.414
280.587
286.035
291.483
38
F-5-14-0
182.753
188.236
191.891
195.546
39
F-5-15-0
171.446
176.590
180.019
183.447
40
F-5-16-0
178.578
183.935
187.507
191.078
41
G-2-10-0
150.376
154.887
157.895
160.903
42
G-2-11-0
1.303.524
1.342.630
1.368.700
1.394.771
43
G-2-12-0

EKSTRAKRANIAL
1.889.128
1.945.801
1.983.584
2.021.366
44
G-2-13-0
463.445
477.348
486.617
495.886
45
G-2-21-0
845.246
870.603
887.508
904.413
46
G-2-22-0
767.132
790.146
805.489
820.832
47
G-2-31-0
1.265.835
1.303.810
1.329.127
1.354.444
48
G-2-32-0
648.866
668.332
681.309
694.287
49
G-3-10-0
257.539
265.265
270.416
275.567
50
G-3-11-0
342.993
353.282
360.142
367.002
51
G-3-12-0
561.999
578.859
590.099
601.339
52
G-3-13-0
562.063
578.925
590.167
601.408
53
H-2-21-0
1.692.142
1.742.907
1.776.750
1.810.592
54
H-2-22-0
439.905
453.102
461.900
470.698
55
H-2-23-0
439.905
453.102
461.900
470.698
56
H-2-31-0
2.802.893
2.886.980
2.943.038
2.999.096
57
H-2-32-0
291.716
300.467
306.302
312.136
58
H-2-33-0
439.905
453.102
461.900
470.698
59
H-2-34-0
1.257.446
1.295.170
1.320.318
1.345.467
60
H-2-35-0
414.357
426.788
435.075
443.362
61
H-2-36-0
2.236.602
2.303.700
2.348.432
2.393.164
62
H-2-37-0

2.380.962
2.452.391
2.500.010
2.547.629
63
H-3-10-0
828.401
853.253
869.821
886.389
64
H-3-11-0
435.647
448.716
457.429
466.142

AKUT
MENTAL
PROSEDUR KRANIOTOMI

MATA
MATA
MATA
MATA
MATA
- 133 No
Kode
INA-CBG
65
H-3-12-0
66
H-3-13-0
67
I-2-11-0
68
I-2-12-0
69
I-2-13-0
70
I-2-14-0
71
I-2-15-0
Deskripsi (INA-CBG)
MATA
TORASIK
ABDOMEN
PENGGANTIAN ALAT
DARAH VENA
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
454.838
468.483
477.579
486.676
441.620
454.869
463.701
472.533
2.220.020
2.286.620
2.331.021
2.375.421
1.560.916
1.607.744
1.638.962
1.670.180
1.983.831
2.043.345
2.083.022
2.122.699
3.510.958
3.616.286
3.686.505
3.756.725
211.142
217.476
221.699
225.922
2.217.614
2.284.142
2.328.495
2.372.847
731.084
753.016
767.638
782.259
72
I-2-16-0
73
I-2-17-0
74
I-2-21-0
1.711.683
1.763.033
1.797.267
1.831.500
75
I-2-22-0
1.611.849
1.660.204
1.692.441
1.724.678
76
I-2-23-0
329.860
339.756
346.353
352.950
77
I-2-31-0
2.565.433
2.642.396
2.693.705
2.745.014
78
I-2-32-0
3.354.681
3.455.321
3.522.415
3.589.508
79
I-2-41-0
2.249.355
2.316.835
2.361.822
2.406.809
80
I-2-42-0

LAIN
2.615.247
2.693.704
2.746.009
2.798.314
81
I-3-10-0
PROSEDUR RESUSITASI
331.982
341.942
348.581
355.221
82
I-3-11-0
175.220
180.476
183.981
187.485
83
I-3-12-0
1.018.310
1.048.859
1.069.225
1.089.591
84
I-3-13-0
334.452
344.486
351.175
357.864
85
I-3-14-0
214.373
220.804
225.091
229.379
189.904
195.601
199.399
203.197
1.175.761
1.211.034
1.234.549
1.258.065
189.532
195.218
199.009
202.800
955.125
983.779
1.002.882
1.021.984
1.238.883
1.276.050
1.300.827
1.325.605

PACU JANTUNG

KARDIOVASKULAR
PERNAFASAN
PENDEK
86
I-3-15-0
87
J-2-10-0
88
J-2-21-0
89
J-2-22-0
90
J-2-31-0
91
J-2-32-0
921.935
949.593
968.031
986.470
92
J-3-10-0
191.760
197.513
201.348
205.183
93
J-3-11-0

PADA DADA
541.879
558.136
568.973
579.811
94
J-3-12-0
209.354
215.634
219.822
224.009
95
J-3-13-0
308.117
317.360
323.522
329.685
96
J-3-14-0
327.099
336.912
343.454
349.996
- 134 No
Kode
INA-CBG
97
J-3-15-0
98
J-3-16-0
99
J-3-17-0
100
K-2-10-0
101
K-2-11-0
102
K-2-12-0

103
K-2-13-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
286.840
295.445
301.182
306.919
327.099
336.912
343.454
349.996
191.760
197.513
201.348
205.183
551.950
568.509
579.548
590.587
1.178.639
1.213.999
1.237.571
1.261.144
904.758
931.900
949.996
968.091
1.472.542
1.516.718
1.546.169
1.575.620
191.760
197.513
201.348
205.183
191.760
197.513
201.348
205.183
2.464.571
2.538.508
2.587.799
2.637.091
828.710
853.571
870.145
886.719
191.760
197.513
201.348
205.183

PERNAFASAN
KECIL

FEMORALIS
USUS BESAR
ATAS
ATAS
104
K-2-14-0
105
K-2-21-0
106
K-2-22-0
107
K-2-31-0
108
K-2-32-0
109
K-2-41-0
912.841
940.226
958.483
976.740
110
K-2-42-0

260.810
268.634
273.850
279.067
111
K-2-51-0
604.904
623.051
635.149
647.247
112
K-2-52-0
329.860
339.756
346.353
352.950
113
K-2-53-0
191.760
197.513
201.348
205.183
114
K-3-10-0

GASTROINTESTINAL
364.906
375.853
383.151
390.450
115
K-3-11-0
219.380
225.961
230.349
234.736
116
K-3-12-0
222.479
229.153
233.603
238.052
117
K-3-13-0
191.760
197.513
201.348
205.183
513.921
529.338
539.617
549.895
248.179
255.625
260.588
265.552
328.854
338.719
345.296
351.873
1.130.610
1.164.529
1.187.141
1.209.753
724.713
746.455
760.949
775.443
327.099
336.912
343.454
349.996
329.860
339.756
346.353
352.950

GASTROINTESTINAL
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
118
K-3-14-0
119
K-3-15-0
120
K-3-16-0
121
L-2-21-0
122
L-2-22-0
123
L-2-31-0
124
L-2-32-0
125
L-2-41-0
987.727
1.017.359
1.037.113
1.056.868
126
L-2-42-0

221.531
228.177
232.608
237.038
127
L-2-51-0
1.478.782
1.523.145
1.552.721
1.582.297
L-2-52-0

1.131.317
1.165.256
1.187.883
1.210.509
128
- 135 No
Kode
INA-CBG
129
L-2-53-0
130
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

191.760
197.513
201.348
205.183
L-3-10-0
260.810
268.634
273.850
279.067
131
L-3-11-0
253.264
260.862
265.928
270.993
132
L-3-12-0
192.885
198.672
202.529
206.387
133
M-2-10-0
1.512.902
1.558.289
1.588.547
1.618.805
134
M-2-21-0
1.354.908
1.395.555
1.422.653
1.449.752
135
M-2-22-0
329.860
339.756
346.353
352.950
136
M-2-31-0
PROSEDUR BUNION
822.971
847.660
864.119
880.578
137
M-2-32-0
260.810
268.634
273.850
279.067
138
M-2-41-0

TULANG
260.810
268.634
273.850
279.067
139
M-2-42-0
89.882
92.579
94.376
96.174
140
M-2-51-0
191.760
197.513
201.348
205.183
141
M-2-52-0
191.760
197.513
201.348
205.183
142
M-2-61-0
PROSEDUR ARTROSKOPI
939.915
968.113
986.911
1.005.709
143
M-2-62-0
191.760
197.513
201.348
205.183
945.000
973.350
992.250
1.011.150
1.288.785
1.327.448
1.353.224
1.379.000
191.760
197.513
201.348
205.183
951.462
980.006
999.035
1.018.064
918.201
945.747
964.111
982.475

DAN WAJAH
PAHA
PAHA

TULANG
WAJAH
WAJAH
BAWAH
BAWAH
144
M-2-63-0
145
M-2-64-0
146
M-2-65-0
147
M-2-71-0
148
M-2-72-0
149
M-2-81-0
1.369.234
1.410.311
1.437.695
1.465.080
150
M-2-82-0
994.660
1.024.500
1.044.393
1.064.287
151
M-2-83-0
191.760
197.513
201.348
205.183
152
M-2-84-0
191.760
197.513
201.348
205.183
153
M-3-10-0
547.320
563.739
574.686
585.632
154
M-3-11-0
303.455
312.559
318.628
324.697
155
M-3-12-0
686.241
706.828
720.553
734.278
156
M-3-13-0
223.733
230.445
234.920
239.394
157
M-3-14-0

TERTUTUP
382.398
393.870
401.517
409.165
158
M-3-15-0
168.470
173.524
176.893
180.262
159
M-3-16-0

191.760
197.513
201.348
205.183
160
M-3-17-0
209.354
215.634
219.822
224.009
161
N-2-11-0
2.533.336
2.609.336
2.660.002
2.710.669

PERGELANGAN TANGAN
PERGELANGAN TANGAN
MUSKULOSKELETAL
SKELETAL
- 136 No
Kode
INA-CBG
162
N-2-12-0
163
N-2-21-0
164
N-2-22-0
165
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.465.510
1.509.475
1.538.785
1.568.095
1.457.785
1.501.518
1.530.674
1.559.830
329.860
339.756
346.353
352.950
N-2-23-0
329.860
339.756
346.353
352.950
166
N-2-24-0
1.065.997
1.097.977
1.119.297
1.140.617
167
N-2-31-0
897.397
924.319
942.267
960.214
168
N-2-32-0
329.860
339.756
346.353
352.950
169
N-2-41-0
329.860
339.756
346.353
352.950
170
N-2-42-0
557.857
574.592
585.749
596.907
171
N-3-10-0
329.860
339.756
346.353
352.950
172
N-3-11-0
382.190
393.656
401.300
408.943
173
N-3-12-0
295.335
304.195
310.102
316.008
174
N-3-13-0
329.860
339.756
346.353
352.950
175
N-3-14-0
283.827
292.341
298.018
303.695
176
N-3-15-0
727.803
749.637
764.193
778.749
177
O-7-10-0
121.512
125.157
127.587
130.018
178
O-7-11-0
669.197
689.273
702.657
716.041
179
O-7-12-0
243.677
250.988
255.861
260.735
180
O-7-13-0
135.425
139.488
142.196
144.905
181
P-9-10-0
180.623
186.042
189.654
193.267
182
P-9-11-0
180.623
186.042
189.654
193.267
183
P-9-12-0
180.623
186.042
189.654
193.267
184
P-9-13-0
180.623
186.042
189.654
193.267
185
P-9-14-0
180.623
186.042
189.654
193.267
186
P-9-15-0
115.133
118.587
120.890
123.192
187
P-9-16-0
180.623
186.042
189.654
193.267
188
P-9-17-0
179.846
185.242
188.839
192.436
189
Q-5-10-0
235.410
242.472
247.180
251.888
190
Q-5-11-0
176.433
181.726
185.255
188.783
191
Q-5-12-0
GIGI
155.503
160.169
163.279
166.389
192
Q-5-13-0
MEDICAL CHECK-UP
118.176
121.721
124.085
126.448
193
Q-5-14-0
130.032
133.933
136.534
139.134


DAN URETHRA
URETHRA
TRANSURETHRA
TRANSURETHRA
SALURAN KEMIH
KEMIH
KEMIH
PROSEDUR DIALISIS
CAESAR
VAGINAL/JALAN LAHIR

ASPIRASI
- 137 No
Kode
INA-CBG
194
Q-5-15-0
195
Q-5-16-0
VAKSINASI
196
Q-5-17-0
PASANG INFUS
197
Q-5-18-0
198
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
89.423
92.106
93.894
95.683
101.069
104.101
106.122
108.143
87.422
90.044
91.793
93.541
164.555
169.492
172.783
176.074
Q-5-19-0
183.963
189.481
193.161
196.840
199
Q-5-20-0
ABORSI MENGANCAM
123.304
127.003
129.469
131.935
200
Q-5-21-0
ABORSI
121.625
125.273
127.706
130.138
201
Q-5-22-0
130.032
133.933
136.534
139.134
202
Q-5-23-0
159.194
163.969
167.153
170.337
203
Q-5-24-0
108.727
111.989
114.163
116.338
204
Q-5-25-0
169.557
174.644
178.035
181.426
205
Q-5-26-0
BRONKIAL AKUT
239.997
247.197
251.997
256.797
206
Q-5-27-0
170.793
175.917
179.333
182.749
207
Q-5-28-0
138.594
142.752
145.524
148.296
208
Q-5-29-0

JANTUNG LAIN-LAIN
392.384
404.155
412.003
419.850
209
Q-5-30-0
454.730
468.372
477.467
486.561
210
Q-5-31-0
FRAKTUR
162.230
167.096
170.341
173.586
211
Q-5-32-0
SALURAN KEMIH AKUT
187.898
193.535
197.293
201.051
212
Q-5-33-0
HEMATOLOGI AKUT
196.729
202.631
206.565
210.500
213
Q-5-34-0
INFEKSI VIRUS HIV
279.467
287.851
293.441
299.030
214
Q-5-35-0
INFEKSI AKUT
316.908
326.416
332.754
339.092
215
Q-5-36-0
369.060
380.132
387.513
394.894
216
Q-5-37-0

SHOCK
188.240
193.887
197.652
201.416
217
Q-5-38-0
PARU AKUT
251.024
258.554
263.575
268.595
218
Q-5-39-0
160.637
165.456
168.668
171.881
219
Q-5-40-0
157.610
162.339
165.491
168.643
220
Q-5-41-0
218.189
224.735
229.098
233.462
221
Q-5-42-0
171.069
176.201
179.622
183.044
222
Q-5-43-0
246.349
253.739
258.666
263.593
223
Q-5-44-0
201.055
207.087
211.108
215.129
224
T-2-10-0

TERAPI DETOKSIKASI
104.284
107.412
109.498
111.584
225
U-2-10-0
1.391.785
1.433.539
1.461.375
1.489.210
226
U-2-11-0

LEHER
1.654.292
1.703.920
1.737.006
1.770.092
227
U-2-12-0
182.015
187.476
191.116
194.756
- 138 No
Kode
INA-CBG
228
U-2-13-0
229
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
238.627
245.785
250.558
255.330
U-2-14-0
443.260
456.558
465.423
474.288
230
U-2-15-0
251.851
259.406
264.443
269.480
231
U-2-21-0
293.367
302.168
308.035
313.902
232
U-2-22-0
566.808
583.812
595.148
606.484
233
U-2-23-0
742.701
764.982
779.836
794.690
234
U-2-24-0
625.936
644.714
657.233
669.751
235
U-2-25-0
238.627
245.785
250.558
255.330
236
U-2-31-0
191.760
197.513
201.348
205.183
237
U-2-32-0
238.627
245.785
250.558
255.330
238
U-3-10-0
228.140
234.984
239.546
244.109
239
U-3-11-0
242.213
249.479
254.324
259.168
240
U-3-12-0
107.106
110.319
112.462
114.604
241
U-3-13-0
235.428
242.491
247.199
251.908
242
U-3-14-0
216.310
222.799
227.125
231.451
243
U-3-15-0
188.641
194.301
198.073
201.846
244
U-3-16-0
PROSEDUR PADA GIGI
212.753
219.136
223.391
227.646
245
V-2-10-0

PROSTAT
2.075.654
2.137.923
2.179.436
2.220.949
246
V-2-11-0
234.081
241.103
245.785
250.467
746.986
769.395
784.335
799.275
329.860
339.756
346.353
352.950
329.860
339.756
346.353
352.950

(RHINOPLASTY)

RONGGA HIDUNG
TENGGOROKAN
PROSEDUR PADA PENIS

SKROTUM
SKROTUM
TRANSURETHRAL
247
V-2-12-0
248
V-2-13-0
249
V-2-14-0
250
V-2-15-0
SIRKUMSISI/SUNAT
180.623
186.042
189.654
193.267
251
V-3-10-0
376.702
388.003
395.537
403.071
252
V-3-11-0
796.919
820.827
836.765
852.704
253
V-3-12-0
460.083
473.885
483.087
492.288
254
W-2-10-0
168.470
173.524
176.893
180.262
255
W-2-11-0
430.545
443.462
452.073
460.684
256
W-2-12-0
796.919
820.827
836.765
852.704
257
W-2-13-0
127.812
131.646
134.202
136.758
258
W-2-21-0
1.602.020
1.650.081
1.682.121
1.714.162
259
W-2-22-0
168.470
173.524
176.893
180.262

PROSEDUR ABORSI
RAHIM & LEHER RAHIM
TERHALANG/TERGANGGU
TERHALANG/TERGANGGU
PANGGUL TERBUKA
PANGGUL TERBUKA
- 139 No
Kode
INA-CBG
260
W-2-23-0
Deskripsi (INA-CBG)
JALAN LAHIR
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
562.191
579.057
590.301
601.545
1.845.502
1.900.867
1.937.777
1.974.688
1.294.335
1.333.165
1.359.051
1.384.938
261
W-2-31-0
262
W-2-32-0
263
W-2-33-0
550.109
566.613
577.615
588.617
264
W-2-34-0
187.102
192.715
196.457
200.199
265
W-3-10-0
454.730
468.372
477.466
486.561
266
W-3-11-0
363.498
374.403
381.673
388.943
267
W-3-12-0
168.470
173.524
176.893
180.262
268
Z-3-10-0
1.907.300
1.964.519
2.002.665
2.040.811
269
Z-3-11-0

EMPEDU
1.457.785
1.501.518
1.530.674
1.559.830
270
Z-3-12-0
243.415
250.717
255.586
260.454
271
Z-3-13-0

LAIN-LAIN
1.485.384
1.529.945
1.559.653
1.589.361
272
Z-3-14-0
DIAGNOSTIK TIDUR
293.706
302.518
308.392
314.266
273
Z-3-15-0
191.760
197.513
201.348
205.183
274
Z-3-16-0

(MRI)
615.491
633.956
646.265
658.575
275
Z-3-17-0
PENGOBATAN NUKLIR
258.396
266.148
271.316
276.484
276
Z-3-18-0
CT-SCAN KEPALA
248.960
256.429
261.408
266.387
277
Z-3-19-0
CT SCAN LAIN-LAIN
259.119
266.892
272.075
277.257
278
Z-3-20-0
176.233
181.520
185.045
188.569
279
Z-3-21-0
168.470
173.524
176.893
180.262
280
Z-3-22-0
189.934
195.632
199.431
203.230
281
Z-3-23-0
197.833
203.768
207.725
211.681
282
Z-3-24-0
388.703
400.364
408.138
415.912
283
Z-3-25-0
173.128
178.321
181.784
185.247
284
Z-3-26-0
195.668
201.538
205.452
209.365
285
Z-3-27-0
PERAWATAN LUKA
186.810
192.415
196.151
199.887
286
Z-3-28-0
IMAGING PAYUDARA
191.760
197.513
201.348
205.183
287
Z-3-29-0
IMAGING LAIN-LAIN
552.686
569.267
580.321
591.375
288
Z-3-30-0
FOTOTERAPI
93.273
96.071
97.937
99.802
- 140 4. RUMAH SAKIT ORTOPEDI KELAS A

a. RawatInap
No
Kode
INA-CBG
A-4-10-i
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
SEPTIKEMIA RINGAN
2.465.712
2.539.683
2.588.997
2.638.311
A-4-10-ii
SEPTIKEMIA SEDANG
4.214.122
4.340.545
4.424.828
4.509.110
A-4-10-iii
SEPTIKEMIA BERAT
6.033.012
6.214.003
6.334.663
6.455.323
A-4-11-i
6.616.191
6.814.677
6.947.001
7.079.324
A-4-11-ii
10.221.251
10.527.888
10.732.313
10.936.738
A-4-11-iii
11.457.171
11.800.886
12.030.030
12.259.173
A-4-12-i
DEMAM RINGAN
2.369.957
2.441.055
2.488.454
2.535.854
A-4-12-ii
DEMAM SEDANG
3.722.563
3.834.240
3.908.691
3.983.142
A-4-12-iii
DEMAM BERAT
4.260.200
4.388.006
4.473.210
4.558.414
10
A-4-13-i
2.962.446
3.051.319
3.110.568
3.169.817
11
A-4-13-ii
3.554.935
3.661.583
3.732.682
3.803.780
12
A-4-13-iii
4.320.603
4.450.221
4.536.633
4.623.045
2.369.957
2.441.055
2.488.454
2.535.854
3.702.592
3.813.669
3.887.721
3.961.773
4.131.984
4.255.944
4.338.583
4.421.223

LAIN-LAIN RINGAN
LAIN-LAIN SEDANG
LAIN-LAIN BERAT
13
A-4-14-i
14
A-4-14-ii
15
A-4-14-iii
16
A-4-15-i
INFEKSI HIV RINGAN
3.554.935
3.661.583
3.732.682
3.803.780
17
A-4-15-ii
INFEKSI HIV SEDANG
5.332.402
5.492.374
5.599.022
5.705.670
18
A-4-15-iii
INFEKSI HIV BERAT
8.121.629
8.365.278
8.527.710
8.690.143
19
B-1-01-i
39.411.995
40.594.355
41.382.595
42.170.834
20
B-1-01-ii
43.481.967
44.786.426
45.656.065
46.525.705
21
B-1-01-iii
76.276.318
78.564.608
80.090.134
81.615.660
22
B-1-10-i
5.109.631
5.262.920
5.365.113
5.467.306
23
B-1-10-ii
13.021.802
13.412.456
13.672.892
13.933.328
24
B-1-10-iii
24.822.059
25.566.721
26.063.162
26.559.603
3.825.408
3.940.170
4.016.678
4.093.187
9.602.135
9.890.199
10.082.242
10.274.284
12.038.694
12.399.855
12.640.629
12.881.403
8.159.733
8.404.525
8.567.720
8.730.914
17.488.304
18.012.953
18.362.719
18.712.485
21.283.925
21.922.443
22.348.121
22.773.800
25
B-1-11-i
26
B-1-11-ii
27
B-1-11-iii
28
B-1-12-i
29
B-1-12-ii
30
B-1-12-iii

(RINGAN)
(SEDANG)
(BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT
- 141 No
Kode
INA-CBG
31
B-1-13-i
32
B-1-13-ii
33
B-1-13-iii
34
B-1-14-i
35
B-1-14-ii
36
B-1-14-iii
37
B-4-10-i
38
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.346.891
5.507.298
5.614.236
5.721.174
8.709.310
8.970.590
9.144.776
9.318.962
12.839.967
13.225.166
13.481.965
13.738.765
7.260.702
7.478.523
7.623.738
7.768.952
8.075.366
8.317.627
8.479.135
8.640.642
12.632.951
13.011.939
13.264.598
13.517.257
2.031.434
2.092.377
2.133.006
2.173.634
B-4-10-ii
2.962.446
3.051.319
3.110.568
3.169.817
39
B-4-10-iii
4.960.105
5.108.908
5.208.110
5.307.312
40
B-4-11-i
4.904.643
5.051.783
5.149.875
5.247.968
41
B-4-11-ii
7.456.282
7.679.971
7.829.097
7.978.222
42
B-4-11-iii
8.030.675
8.271.595
8.432.209
8.592.822
43
B-4-12-i
4.303.488
4.432.593
4.518.663
4.604.733
44
B-4-12-ii
6.101.288
6.284.326
6.406.352
6.528.378
45
B-4-12-iii
11.595.355
11.943.216
12.175.123
12.407.030
46
B-4-13-i
3.554.935
3.661.583
3.732.682
3.803.780
47
B-4-13-ii
4.213.587
4.339.994
4.424.266
4.508.538
48
B-4-13-iii
7.490.720
7.715.441
7.865.255
8.015.070
49
B-4-14-i
3.726.807
3.838.611
3.913.147
3.987.683
50
B-4-14-ii
4.187.903
4.313.540
4.397.298
4.481.056
51
B-4-14-iii
5.533.081
5.699.073
5.809.735
5.920.396
52
C-4-10-i
3.791.118
3.904.851
3.980.673
4.056.496
53
C-4-10-ii
7.365.744
7.586.716
7.734.031
7.881.346
54
C-4-10-iii
LEUKEMIA AKUT BERAT
11.257.294
11.595.012
11.820.158
12.045.304
55
C-4-11-i
3.813.851
3.928.267
4.004.544
4.080.821
56
C-4-11-ii
4.739.913
4.882.111
4.976.909
5.071.707
57
C-4-11-iii
8.825.023
9.089.774
9.266.275
9.442.775
58
C-4-12-i
RADIOTERAPI RINGAN
2.369.957
2.441.055
2.488.454
2.535.854
59
C-4-12-ii
RADIOTERAPI SEDANG
7.145.965
7.360.344
7.503.263
7.646.183
60
C-4-12-iii
RADIOTERAPI BERAT
14.507.741
14.942.973
15.233.128
15.523.283
61
C-4-13-i
KEMOTERAPI RINGAN
2.369.957
2.441.055
2.488.454
2.535.854
62
C-4-13-ii
KEMOTERAPI SEDANG
4.739.913
4.882.111
4.976.909
5.071.707
63
C-4-13-iii
KEMOTERAPI BERAT
6.201.826
6.387.880
6.511.917
6.635.953

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT

PANCREAS RINGAN
PANCREAS SEDANG
PANCREAS BERAT
(RINGAN)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT
- 142 No
Kode
INA-CBG
64
C-4-14-i
65
C-4-14-ii
66
C-4-14-iii
67
D-1-10-i
68
D-1-10-ii
69
D-1-10-iii
70
D-1-11-i
71
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.365.561
3.466.527
3.533.839
3.601.150
4.917.972
5.065.512
5.163.871
5.262.230
7.497.307
7.722.226
7.872.172
8.022.118
25.219.149
25.975.723
26.480.106
26.984.489
38.410.698
39.563.019
40.331.233
41.099.446
52.056.991
53.618.701
54.659.840
55.700.980
5.676.706
5.847.007
5.960.541
6.074.075
D-1-11-ii
14.805.891
15.250.068
15.546.185
15.842.303
72
D-1-11-iii
20.370.611
20.981.730
21.389.142
21.796.554
73
D-1-20-i
6.385.077
6.576.629
6.704.330
6.832.032
74
D-1-20-ii
14.366.422
14.797.415
15.084.743
15.372.072
75
D-1-20-iii
27.934.710
28.772.751
29.331.445
29.890.140
76
D-4-10-i
2.276.489
2.344.784
2.390.313
2.435.843
77
D-4-10-ii
4.596.659
4.734.559
4.826.492
4.918.425
78
D-4-10-iii
5.924.891
6.102.638
6.221.136
6.339.634
79
D-4-11-i
2.962.446
3.051.319
3.110.568
3.169.817
80
D-4-11-ii
5.461.945
5.625.804
5.735.042
5.844.281
81
D-4-11-iii
8.274.086
8.522.309
8.687.791
8.853.272
82
D-4-12-i
3.038.904
3.130.071
3.190.849
3.251.627
83
D-4-12-ii
4.215.259
4.341.716
4.426.022
4.510.327
84
D-4-12-iii
6.472.532
6.666.708
6.796.158
6.925.609
85
D-4-13-i
2.369.957
2.441.055
2.488.454
2.535.854
86
D-4-13-ii
3.554.935
3.661.583
3.732.682
3.803.780
87
D-4-13-iii
4.147.424
4.271.847
4.354.795
4.437.744
88
D-4-14-i
2.962.446
3.051.319
3.110.568
3.169.817
89
D-4-14-ii
6.666.914
6.866.922
7.000.260
7.133.598
90
D-4-14-iii
7.952.706
8.191.287
8.350.341
8.509.395
91
E-1-01-i
6.221.488
6.408.132
6.532.562
6.656.992
92
E-1-01-ii
8.149.557
8.394.043
8.557.035
8.720.026
93
E-1-01-iii
16.866.598
17.372.596
17.709.928
18.047.260
94
E-1-10-i
5.788.672
5.962.332
6.078.105
6.193.879
95
E-1-10-ii
7.026.089
7.236.872
7.377.393
7.517.915
96
E-1-10-iii
14.808.927
15.253.195
15.549.373
15.845.552

RINGAN
SEDANG
BERAT
TULANG RINGAN
TULANG SEDANG
TULANG BERAT


RINGAN
SEDANG
BERAT
- 143 No
Kode
INA-CBG
97
E-1-20-i
98
E-1-20-ii
99
E-1-20-iii
100
E-4-10-i
101
E-4-10-ii
102
E-4-10-iii
103
E-4-11-i
104
E-4-11-ii
105
E-4-11-iii
106
E-4-12-i
107
E-4-12-ii
108
E-4-12-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
7.341.113
7.561.347
7.708.169
7.854.991
9.832.235
10.127.202
10.323.847
10.520.492
21.785.454
22.439.018
22.874.727
23.310.436
3.012.264
3.102.632
3.162.878
3.223.123
4.614.036
4.752.457
4.844.737
4.937.018
8.053.490
8.295.094
8.456.164
8.617.234
2.768.041
2.851.082
2.906.443
2.961.804
5.236.659
5.393.758
5.498.492
5.603.225
8.635.492
8.894.556
9.067.266
9.239.976
3.258.690
3.356.451
3.421.625
3.486.799
5.332.402
5.492.374
5.599.022
5.705.670
8.567.138
8.824.152
8.995.495
9.166.838
3.488.683
3.593.344
3.663.118
3.732.891
5.990.094
6.169.797
6.289.598
6.409.400
10.364.375
10.675.306
10.882.594
11.089.881

RINGAN
SEDANG
BERAT

RINGAN
SEDANG
BERAT
109
E-4-13-i
110
E-4-13-ii
111
E-4-13-iii
112
F-4-10-i
SCHIZOFRENIA RINGAN
4.265.575
4.393.543
4.478.854
4.564.166
113
F-4-10-ii
SCHIZOFRENIA SEDANG
4.737.059
4.879.170
4.973.912
5.068.653
114
F-4-10-iii
SCHIZOFRENIA BERAT
7.013.320
7.223.719
7.363.986
7.504.252
115
F-4-11-i
3.931.827
4.049.782
4.128.419
4.207.055
116
F-4-11-ii
4.580.952
4.718.381
4.810.000
4.901.619
117
F-4-11-iii
DEPRESI MAYOR BERAT
5.874.455
6.050.688
6.168.177
6.285.667
1.920.048
1.977.650
2.016.050
2.054.451
2.537.971
2.614.111
2.664.870
2.715.629
5.505.703
5.670.874
5.780.988
5.891.102

IMPULSE RINGAN
IMPULSE SEDANG
IMPULSE BERAT
118
F-4-12-i
119
F-4-12-ii
120
F-4-12-iii
121
F-4-13-i
3.177.514
3.272.839
3.336.389
3.399.940
122
F-4-13-ii
4.207.845
4.334.080
4.418.237
4.502.394
123
F-4-13-iii
5.425.479
5.588.243
5.696.753
5.805.262
124
F-4-14-i
DEPRESI RINGAN
2.224.260
2.290.988
2.335.473
2.379.958
125
F-4-14-ii
DEPRESI SEDANG
2.853.064
2.938.656
2.995.717
3.052.779
126
F-4-14-iii
DEPRESI BERAT
3.838.925
3.954.093
4.030.871
4.107.650
127
F-4-15-i
2.644.518
2.723.854
2.776.744
2.829.634
128
F-4-15-ii
3.722.934
3.834.622
3.909.081
3.983.540
129
F-4-15-iii
4.682.067
4.822.529
4.916.171
5.009.812
- 144 No
Kode
INA-CBG
130
F-4-16-i
131
F-4-16-ii
132
F-4-16-iii
133
F-4-17-i
134
F-4-17-ii
135
F-4-17-iii
136
F-4-18-i
137
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.695.775
5.866.648
5.980.564
6.094.479
6.621.196
6.819.831
6.952.255
7.084.679
8.838.191
9.103.336
9.280.100
9.456.864
1.200.847
1.236.873
1.260.890
1.284.907
3.519.569
3.625.156
3.695.548
3.765.939
3.755.121
3.867.775
3.942.878
4.017.980
4.936.906
5.085.013
5.183.751
5.282.489
F-4-18-ii
5.431.991
5.594.950
5.703.590
5.812.230
138
F-4-18-iii
8.373.887
8.625.103
8.792.581
8.960.059
139
F-4-19-i
3.786.141
3.899.725
3.975.448
4.051.171
140
F-4-19-ii
4.848.251
4.993.698
5.090.663
5.187.628
141
F-4-19-iii
6.036.137
6.217.221
6.337.944
6.458.666
142
G-1-01-i
10.991.318
11.321.057
11.540.884
11.760.710
143
G-1-01-ii
18.604.130
19.162.254
19.534.337
19.906.419
144
G-1-01-iii
36.015.518
37.095.984
37.816.294
38.536.604
145
G-1-10-i
6.007.045
6.187.256
6.307.397
6.427.538
146
G-1-10-ii
8.480.454
8.734.868
8.904.477
9.074.086
147
G-1-10-iii
10.051.149
10.352.684
10.553.707
10.754.730
148
G-1-11-i
6.929.306
7.137.185
7.275.771
7.414.357
149
G-1-11-ii
14.229.851
14.656.747
14.941.344
15.225.941
150
G-1-11-iii
29.796.014
30.689.895
31.285.815
31.881.735
151
G-1-12-i
5.388.958
5.550.627
5.658.406
5.766.185
152
G-1-12-ii
12.337.483
12.707.608
12.954.357
13.201.107
153
G-1-12-iii
21.241.611
21.878.859
22.303.691
22.728.523
154
G-1-13-i
2.051.934
2.113.492
2.154.531
2.195.569
155
G-1-13-ii
5.511.268
5.676.606
5.786.832
5.897.057
156
G-1-13-iii
12.435.743
12.808.815
13.057.530
13.306.245
6.790.546
6.994.262
7.130.073
7.265.884
9.174.250
9.449.477
9.632.962
9.816.447
22.462.071
23.135.934
23.585.175
24.034.416

RINGAN
SEDANG
BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

RINGAN
SEDANG
BERAT
157
G-1-20-i
158
G-1-20-ii
159
G-1-20-iii
160
G-1-30-i
13.693.617
14.104.426
14.378.298
14.652.171
161
G-1-30-ii
35.741.654
36.813.904
37.528.737
38.243.570
162
G-1-30-iii
46.010.554
47.390.871
48.311.082
49.231.293
- 145 No
Kode
INA-CBG
163
G-4-10-i
164
G-4-10-ii
165
G-4-10-iii
166
G-4-11-i
167
G-4-11-ii
168
G-4-11-iii
169
G-4-12-i
170
G-4-12-ii
171
G-4-12-iii
172
G-4-13-i
173
G-4-13-ii
174
G-4-13-iii
175
G-4-14-i
176
G-4-14-ii
177
G-4-14-iii
178
G-4-15-i
179
G-4-15-ii
180
G-4-15-iii
181
G-4-16-i
182
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.620.764
5.789.387
5.901.802
6.014.217
6.557.558
6.754.285
6.885.436
7.016.587
10.971.180
11.300.315
11.519.739
11.739.162
6.423.377
6.616.078
6.744.545
6.873.013
7.451.117
7.674.650
7.823.673
7.972.695
10.919.740
11.247.332
11.465.727
11.684.122
4.804.120
4.948.244
5.044.326
5.140.409
6.053.192
6.234.787
6.355.851
6.476.915
8.791.540
9.055.287
9.231.117
9.406.948
2.672.980
2.753.170
2.806.629
2.860.089
4.147.424
4.271.847
4.354.795
4.437.744
4.902.844
5.049.929
5.147.986
5.246.043
4.888.483
5.035.137
5.132.907
5.230.676
8.043.204
8.284.500
8.445.364
8.606.228
10.070.274
10.372.382
10.573.788
10.775.193
3.554.935
3.661.583
3.732.682
3.803.780
4.506.857
4.642.063
4.732.200
4.822.337
6.822.177
7.026.842
7.163.286
7.299.729
2.962.446
3.051.319
3.110.568
3.169.817
G-4-16-ii
4.430.364
4.563.275
4.651.883
4.740.490
183
G-4-16-iii
8.040.320
8.281.529
8.442.336
8.603.142
184
G-4-17-i
4.636.359
4.775.450
4.868.177
4.960.904
185
G-4-17-ii
5.753.926
5.926.544
6.041.622
6.156.701
186
G-4-17-iii
9.643.627
9.932.936
10.125.808
10.318.681
187
G-4-18-i
3.554.935
3.661.583
3.732.682
3.803.780
188
G-4-18-ii
5.582.067
5.749.529
5.861.170
5.972.811
189
G-4-18-iii
5.913.631
6.091.040
6.209.313
6.327.586
190
G-4-19-i
3.242.538
3.339.814
3.404.665
3.469.516
191
G-4-19-ii
6.003.795
6.183.908
6.303.984
6.424.060
192
G-4-19-iii
8.955.756
9.224.428
9.403.543
9.582.659

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
DEGENERATIF RINGAN
DEGENERATIF SEDANG
DEGENERATIF BERAT
RINGAN
SEDANG
BERAT
TRAUMATIK RINGAN
TRAUMATIK SEDANG
TRAUMATIK BERAT
DENGAN INFARK BERAT
TANPA INFARK RINGAN
TANPA INFARK SEDANG
TANPA INFARK BERAT

PERIFER RINGAN
PERIFER SEDANG
PERIFER BERAT
PERSARAFAN RINGAN
PERSARAFAN SEDANG
PERSARAFAN BERAT
SEDANG
- 146 No
Kode
INA-CBG
193
G-4-20-i
194
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.073.712
2.135.923
2.177.398
2.218.872
G-4-20-ii
2.944.673
3.033.013
3.091.907
3.150.800
195
G-4-20-iii
5.021.358
5.171.999
5.272.426
5.372.853
196
G-4-21-i
2.631.557
2.710.504
2.763.135
2.815.766
197
G-4-21-ii
5.450.218
5.613.725
5.722.729
5.831.734
198
G-4-21-iii
6.421.000
6.613.630
6.742.050
6.870.470
199
G-4-22-i
2.369.957
2.441.055
2.488.454
2.535.854
200
G-4-22-ii
2.962.446
3.051.319
3.110.568
3.169.817
201
G-4-22-iii
3.398.700
3.500.661
3.568.635
3.636.609
202
G-4-23-i
2.369.957
2.441.055
2.488.454
2.535.854
203
G-4-23-ii
2.962.446
3.051.319
3.110.568
3.169.817
204
G-4-23-iii
4.234.606
4.361.644
4.446.337
4.531.029
205
G-4-24-i
2.369.957
2.441.055
2.488.454
2.535.854
206
G-4-24-ii
2.962.446
3.051.319
3.110.568
3.169.817
207
G-4-24-iii
TRAUMA KEPALA BERAT
6.225.259
6.412.017
6.536.522
6.661.027
208
G-4-25-i
GEGAR OTAK RINGAN
2.369.957
2.441.055
2.488.454
2.535.854
209
G-4-25-ii
GEGAR OTAK SEDANG
2.962.446
3.051.319
3.110.568
3.169.817
210
G-4-25-iii
GEGAR OTAK BERAT
3.699.176
3.810.152
3.884.135
3.958.119
211
G-4-26-i
3.911.295
4.028.634
4.106.860
4.185.086
212
G-4-26-ii
4.435.540
4.568.606
4.657.317
4.746.027
213
G-4-26-iii
7.916.852
8.154.358
8.312.695
8.471.032
214
H-1-20-i
3.730.630
3.842.549
3.917.161
3.991.774
215
H-1-20-ii
6.803.226
7.007.323
7.143.387
7.279.452
216
H-1-20-iii
9.251.962
9.529.521
9.714.560
9.899.599
217
H-1-30-i
3.652.642
3.762.221
3.835.274
3.908.327
218
H-1-30-ii
4.164.012
4.288.932
4.372.212
4.455.493
219
H-1-30-iii
6.947.503
7.155.928
7.294.878
7.433.828
220
H-4-10-i
3.554.935
3.661.583
3.732.682
3.803.780
221
H-4-10-ii
5.924.891
6.102.638
6.221.136
6.339.634
222
H-4-10-iii
9.659.323
9.949.103
10.142.289
10.335.475
223
H-4-11-i
2.650.790
2.730.314
2.783.330
2.836.345
224
H-4-11-ii
2.925.963
3.013.742
3.072.261
3.130.781
225
H-4-11-iii
3.867.283
3.983.302
4.060.647
4.137.993
226
H-4-12-i
3.677.865
3.788.201
3.861.759
3.935.316

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)

RINGAN
SEDANG
- 147 No
Kode
INA-CBG
227
H-4-12-ii
228
H-4-12-iii
229
I-1-01-i
230
I-1-01-ii
231
I-1-01-iii
232
I-1-02-i
233
I-1-02-ii
234
I-1-02-iii
235
I-1-03-i
236
I-1-03-ii
237
I-1-03-iii
238
I-1-04-i
239
I-1-04-ii
240
I-1-04-iii
241
I-1-05-i
242
I-1-05-ii
243
I-1-05-iii
244
I-1-06-i
245
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.981.909
5.131.366
5.231.005
5.330.643
8.311.976
8.561.335
8.727.574
8.893.814
51.128.973
52.662.843
53.685.422
54.708.002
52.254.077
53.821.700
54.866.781
55.911.863
82.482.059
84.956.521
86.606.162
88.255.803
28.366.060
29.217.042
29.784.363
30.351.684
36.592.217
37.689.984
38.421.828
39.153.672
45.102.035
46.455.096
47.357.137
48.259.178
17.468.829
17.992.894
18.342.270
18.691.647
23.944.037
24.662.358
25.141.239
25.620.120
35.117.921
36.171.459
36.873.817
37.576.176
23.338.871
24.039.038
24.505.815
24.972.592
29.979.195
30.878.571
31.478.154
32.077.738
63.909.419
65.826.701
67.104.890
68.383.078
37.543.315
38.669.614
39.420.480
40.171.347
45.051.977
46.403.537
47.304.576
48.205.616
61.991.237
63.850.974
65.090.799
66.330.623
19.380.654
19.962.073
20.349.686
20.737.299
I-1-06-ii
29.250.006
30.127.507
30.712.507
31.297.507
246
I-1-06-iii
34.384.165
35.415.690
36.103.373
36.791.056
247
I-1-07-i
25.487.027
26.251.638
26.761.378
27.271.119
248
I-1-07-ii
31.443.425
32.386.728
33.015.596
33.644.465
249
I-1-07-iii
34.304.573
35.333.710
36.019.801
36.705.893
250
I-1-11-i
4.848.254
4.993.702
5.090.667
5.187.632
251
I-1-11-ii
5.390.774
5.552.497
5.660.312
5.768.128
252
I-1-11-iii
7.173.477
7.388.681
7.532.150
7.675.620
253
I-1-12-i
13.568.288
13.975.336
14.246.702
14.518.068
254
I-1-12-ii
18.826.632
19.391.431
19.767.964
20.144.497
255
I-1-12-iii
26.258.708
27.046.469
27.571.644
28.096.818

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
KATETERISASI RINGAN
KATETERISASI SEDANG
KATETERISASI BERAT
RINGAN
SEDANG
BERAT

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
- 148 No
Kode
INA-CBG
256
I-1-13-i
257
I-1-13-ii
258
I-1-13-iii
259
I-1-14-i
260
I-1-14-ii
261
I-1-14-iii
262
I-1-15-i
263
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
7.981.346
8.220.786
8.380.413
8.540.040
9.285.807
9.564.381
9.750.097
9.935.813
18.537.750
19.093.883
19.464.638
19.835.393
29.200.356
30.076.366
30.660.374
31.244.381
36.291.871
37.380.627
38.106.464
38.832.302
47.554.865
48.981.511
49.932.608
50.883.706
6.266.205
6.454.191
6.579.515
6.704.839
I-1-15-ii
16.760.826
17.263.651
17.598.867
17.934.084
264
I-1-15-iii
86.756.538
89.359.234
91.094.365
92.829.496
265
I-1-16-i
12.514.438
12.889.871
13.140.160
13.390.449
266
I-1-16-ii
32.537.539
33.513.665
34.164.416
34.815.167
267
I-1-16-iii
37.531.253
38.657.191
39.407.816
40.158.441
268
I-1-17-i
4.395.293
4.527.152
4.615.058
4.702.964
269
I-1-17-ii
9.104.246
9.377.373
9.559.458
9.741.543
270
I-1-17-iii
52.780.880
54.364.307
55.419.924
56.475.542
271
I-1-20-i
7.103.398
7.316.500
7.458.568
7.600.635
272
I-1-20-ii
11.735.921
12.087.999
12.322.717
12.557.436
273
I-1-20-iii
23.764.812
24.477.757
24.953.053
25.428.349
274
I-1-30-i
14.197.695
14.623.626
14.907.580
15.191.534
275
I-1-30-ii
29.534.074
30.420.096
31.010.778
31.601.459
276
I-1-30-iii
45.767.088
47.140.101
48.055.443
48.970.784
277
I-1-40-i
20.909.035
21.536.306
21.954.487
22.372.668
278
I-1-40-ii
28.331.994
29.181.954
29.748.594
30.315.234
279
I-1-40-iii
35.041.671
36.092.921
36.793.755
37.494.588
280
I-4-10-i
6.080.955
6.263.384
6.385.003
6.506.622
281
I-4-10-ii
9.601.937
9.889.995
10.082.034
10.274.073
282
I-4-10-iii
13.851.632
14.267.181
14.544.213
14.821.246
283
I-4-11-i
7.210.423
7.426.735
7.570.944
7.715.152
284
I-4-11-ii
8.887.337
9.153.957
9.331.704
9.509.451

KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

DARAH VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
- 149 No
Kode
INA-CBG
285
I-4-11-iii
286
I-4-12-i
287
288
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
14.419.681
14.852.271
15.140.665
15.429.059
6.315.581
6.505.048
6.631.360
6.757.671
I-4-12-ii
9.012.316
9.282.685
9.462.931
9.643.178
I-4-12-iii
10.933.207
11.261.203
11.479.867
11.698.531
5.673.127
5.843.321
5.956.784
6.070.246
8.241.896
8.489.153
8.653.991
8.818.829
15.404.718
15.866.859
16.174.953
16.483.048

VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
289
I-4-13-i
290
I-4-13-ii
291
I-4-13-iii
292
I-4-14-i
3.528.161
3.634.006
3.704.569
3.775.133
293
I-4-14-ii
4.128.470
4.252.324
4.334.894
4.417.463
294
I-4-14-iii
6.397.756
6.589.688
6.717.643
6.845.599
4.739.913
4.882.111
4.976.909
5.071.707
7.430.934
7.653.862
7.802.481
7.951.100
8.469.477
8.723.561
8.892.951
9.062.341

295
I-4-15-i
296
I-4-15-ii
297
I-4-15-iii
298
I-4-16-i
3.554.935
3.661.583
3.732.682
3.803.780
299
I-4-16-ii
5.761.325
5.934.165
6.049.391
6.164.618
300
I-4-16-iii
7.258.246
7.475.994
7.621.159
7.766.324
301
I-4-17-i
HIPERTENSI RINGAN
3.484.266
3.588.794
3.658.479
3.728.165
302
I-4-17-ii
HIPERTENSI SEDANG
4.753.173
4.895.768
4.990.831
5.085.895
303
I-4-17-iii
HIPERTENSI BERAT
5.555.505
5.722.170
5.833.280
5.944.390
5.131.323
5.285.262
5.387.889
5.490.515
7.860.843
8.096.668
8.253.885
8.411.102
10.597.676
10.915.607
11.127.560
11.339.514
4.015.933
4.136.411
4.216.729
4.297.048
6.519.285
6.714.863
6.845.249
6.975.635
7.467.633
7.691.662
7.841.015
7.990.367

RINGAN
SEDANG
KONGENITAL BERAT
RINGAN
SEDANG
BERAT
304
I-4-18-i
305
I-4-18-ii
306
I-4-18-iii
307
I-4-19-i
308
I-4-19-ii
309
I-4-19-iii
310
I-4-20-i
4.873.903
5.020.120
5.117.598
5.215.076
311
I-4-20-ii
5.615.101
5.783.554
5.895.856
6.008.158
312
I-4-20-iii
7.452.173
7.675.738
7.824.782
7.973.825
313
I-4-21-i
6.481.502
6.675.947
6.805.577
6.935.207
314
I-4-21-ii
8.085.254
8.327.811
8.489.516
8.651.221
315
I-4-21-iii
11.030.000
11.360.900
11.581.500
11.802.100
316
I-4-22-i
3.851.179
3.966.715
4.043.738
4.120.762
317
I-4-22-ii
4.437.711
4.570.843
4.659.597
4.748.351
- 150 No
Kode
INA-CBG
318
I-4-22-iii
Deskripsi (INA-CBG)
PROSEDUR VENTILASI MEKANIKAL LONG
TERM DENGAN TRAKEOSTOMI RINGAN
TERM DENGAN TRAKEOSTOMI SEDANG
TERM DENGAN TRAKEOSTOMI BERAT
TERM TANPA TRAKEOSTOMI RINGAN
TERM TANPA TRAKEOSTOMI SEDANG
TERM TANPA TRAKEOSTOMI BERAT
RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
6.474.500
6.668.735
6.798.225
6.927.715
2.917.486
3.005.010
3.063.360
3.121.710
3.582.000
3.689.460
3.761.100
3.832.740
6.998.902
7.208.869
7.348.847
7.488.825
3.810.752
3.925.075
4.001.290
4.077.505
9.514.394
9.799.825
9.990.113
10.180.401
12.029.232
12.390.109
12.630.694
12.871.278
30.702.058
31.623.120
32.237.161
32.851.202
32.798.898
33.782.864
34.438.842
35.094.820
56.037.109
57.718.223
58.838.965
59.959.707
15.694.283
16.165.112
16.478.998
16.792.883
16.812.759
17.317.142
17.653.397
17.989.652
24.844.467
25.589.801
26.086.691
26.583.580
6.124.136
6.307.860
6.430.343
6.552.826
14.792.015
15.235.775
15.531.615
15.827.456
26.191.080
26.976.812
27.500.634
28.024.455
5.293.213
5.452.010
5.557.874
5.663.738
7.698.561
7.929.518
8.083.489
8.237.460
11.576.258
11.923.545
12.155.071
12.386.596
3.569.506
3.676.591
3.747.981
3.819.371
15.962.691
16.441.572
16.760.826
17.080.080
48.142.776
49.587.060
50.549.915
51.512.771
319
I-4-23-i
320
I-4-23-ii
321
I-4-23-iii
322
I-4-24-i
323
I-4-24-ii
324
I-4-24-iii
325
J-1-01-i
326
J-1-01-ii
327
J-1-01-iii
328
J-1-02-i
329
J-1-02-ii
330
J-1-02-iii
331
J-1-10-i
332
J-1-10-ii
333
J-1-10-iii
334
J-1-20-i
335
J-1-20-ii
336
J-1-20-iii
337
J-1-30-i
338
J-1-30-ii
339
J-1-30-iii
340
J-4-10-i
3.761.816
3.874.670
3.949.906
4.025.143
341
J-4-10-ii
5.378.944
5.540.313
5.647.892
5.755.471
342
J-4-10-iii
8.137.540
8.381.666
8.544.417
8.707.168
343
J-4-11-i
2.598.998
2.676.968
2.728.948
2.780.928
344
J-4-11-ii
3.617.746
3.726.278
3.798.633
3.870.988
345
J-4-11-iii
5.184.322
5.339.852
5.443.538
5.547.225
346
J-4-12-i
EMBOLI PARU RINGAN
3.629.280
3.738.159
3.810.745
3.883.330
347
J-4-12-ii
EMBOLI PARU SEDANG
4.699.794
4.840.788
4.934.784
5.028.780
348
J-4-12-iii
EMBOLI PARU BERAT
6.276.100
6.464.383
6.589.905
6.715.427
- 151 No
Kode
INA-CBG
349
J-4-13-i
350
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
6.122.306
6.305.975
6.428.421
6.550.867
J-4-13-ii
8.999.789
9.269.783
9.449.779
9.629.774
351
J-4-13-iii
14.632.310
15.071.280
15.363.926
15.656.572
352
J-4-14-i
TUMOR PARU RINGAN
4.172.158
4.297.323
4.380.766
4.464.209
353
J-4-14-ii
TUMOR PARU SEDANG
6.988.935
7.198.603
7.338.382
7.478.161
354
J-4-14-iii
TUMOR PARU BERAT
8.309.489
8.558.773
8.724.963
8.891.153
3.652.565
3.762.142
3.835.194
3.908.245
5.143.029
5.297.320
5.400.181
5.503.041
6.462.874
6.656.761
6.786.018
6.915.276
2.962.446
3.051.319
3.110.568
3.169.817
4.293.913
4.422.731
4.508.609
4.594.487
7.481.516
7.705.962
7.855.592
8.005.223

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
355
J-4-15-i
356
J-4-15-ii
357
J-4-15-iii
358
J-4-16-i
359
J-4-16-ii
360
J-4-16-iii
361
J-4-17-i
2.990.332
3.080.042
3.139.849
3.199.656
362
J-4-17-ii
4.058.749
4.180.511
4.261.686
4.342.861
363
J-4-17-iii
6.535.543
6.731.609
6.862.320
6.993.031
364
J-4-18-i
2.369.957
2.441.055
2.488.454
2.535.854
365
J-4-18-ii
3.258.690
3.356.451
3.421.625
3.486.799
366
J-4-18-iii
3.431.201
3.534.137
3.602.761
3.671.385
367
J-4-19-i
4.147.424
4.271.847
4.354.795
4.437.744
368
J-4-19-ii
5.142.991
5.297.281
5.400.141
5.503.001
369
J-4-19-iii
7.425.630
7.648.398
7.796.911
7.945.424
370
J-4-20-i
4.183.125
4.308.618
4.392.281
4.475.943
371
J-4-20-ii
5.540.375
5.706.586
5.817.393
5.928.201
372
J-4-20-iii
11.431.721
11.774.673
12.003.307
12.231.942
2.369.957
2.441.055
2.488.454
2.535.854
5.847.115
6.022.529
6.139.471
6.256.413
8.339.899
8.590.096
8.756.894
8.923.692
6.385.077
6.576.629
6.704.330
6.832.032
9.758.500
10.051.255
10.246.425
10.441.595
11.428.883
11.771.750
12.000.328
12.228.905

USUS BESAR (RINGAN)
USUS BESAR (SEDANG)
USUS BESAR (BERAT)
373
J-4-21-i
374
J-4-21-ii
375
J-4-21-iii
376
K-1-10-i
377
K-1-10-ii
378
K-1-10-iii
379
K-1-11-i
6.012.479
6.192.853
6.313.103
6.433.352
380
K-1-11-ii
7.893.659
8.130.469
8.288.342
8.446.215
381
K-1-11-iii
20.032.552
20.633.529
21.034.180
21.434.831
- 152 No
Kode
INA-CBG
382
K-1-12-i
383
K-1-12-ii
384
K-1-12-iii
385
K-1-13-i
386
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.234.253
3.331.281
3.395.966
3.460.651
4.215.233
4.341.690
4.425.994
4.510.299
8.384.984
8.636.533
8.804.233
8.971.933
3.673.669
3.783.879
3.857.352
3.930.825
K-1-13-ii
6.416.844
6.609.349
6.737.686
6.866.023
387
K-1-13-iii
6.862.583
7.068.460
7.205.712
7.342.964
388
K-1-14-i
5.936.866
6.114.972
6.233.709
6.352.446
389
K-1-14-ii
6.973.521
7.182.727
7.322.197
7.461.668
390
K-1-14-iii
17.170.831
17.685.956
18.029.373
18.372.790
391
K-1-20-i
11.519.261
11.864.839
12.095.224
12.325.609
392
K-1-20-ii
16.077.850
16.560.186
16.881.743
17.203.300
393
K-1-20-iii
34.343.048
35.373.339
36.060.200
36.747.061
394
K-1-30-i
7.582.551
7.810.027
7.961.678
8.113.329
395
K-1-30-ii
12.770.153
13.153.258
13.408.661
13.664.064
396
K-1-30-iii
21.779.858
22.433.254
22.868.851
23.304.448
397
K-1-40-i
7.617.588
7.846.115
7.998.467
8.150.819
398
K-1-40-ii
8.382.399
8.633.871
8.801.519
8.969.166
399
K-1-40-iii
13.901.401
14.318.443
14.596.471
14.874.499
400
K-1-50-i
5.810.381
5.984.693
6.100.901
6.217.108
401
K-1-50-ii
7.524.718
7.750.460
7.900.954
8.051.448
402
K-1-50-iii
PROSEDUR ANAL BERAT
10.683.098
11.003.591
11.217.253
11.430.915
403
K-4-10-i
4.400.946
4.532.974
4.620.993
4.709.012
404
K-4-10-ii
5.265.990
5.423.970
5.529.290
5.634.610
405
K-4-10-iii
19.912.109
20.509.473
20.907.715
21.305.957
406
K-4-11-i
2.369.957
2.441.055
2.488.454
2.535.854
407
K-4-11-ii
3.554.935
3.661.583
3.732.682
3.803.780
408
K-4-11-iii
6.460.597
6.654.415
6.783.627
6.912.839
409
K-4-12-i
2.369.957
2.441.055
2.488.454
2.535.854
410
K-4-12-ii
3.877.512
3.993.837
4.071.387
4.148.938
411
K-4-12-iii
9.305.752
9.584.925
9.771.040
9.957.155
412
K-4-13-i
3.554.935
3.661.583
3.732.682
3.803.780
413
K-4-13-ii
4.604.516
4.742.651
4.834.742
4.926.832


RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)

(RINGAN)
(SEDANG)
- 153 No
Kode
INA-CBG
414
K-4-13-iii
415
K-4-14-i
416
K-4-14-ii
417
K-4-14-iii
418
K-4-15-i
419
K-4-15-ii
420
K-4-15-iii
421
K-4-16-i
422
423
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
7.530.973
7.756.902
7.907.522
8.058.141
2.962.446
3.051.319
3.110.568
3.169.817
4.009.361
4.129.642
4.209.829
4.290.016
6.064.541
6.246.477
6.367.768
6.489.059
2.962.446
3.051.319
3.110.568
3.169.817
5.570.206
5.737.312
5.848.716
5.960.120
7.925.400
8.163.162
8.321.670
8.480.178
2.962.446
3.051.319
3.110.568
3.169.817
K-4-16-ii
3.554.935
3.661.583
3.732.682
3.803.780
K-4-16-iii
4.752.064
4.894.626
4.989.668
5.084.709
2.369.957
2.441.055
2.488.454
2.535.854
3.786.761
3.900.364
3.976.099
4.051.834
5.039.792
5.190.986
5.291.782
5.392.578
2.586.963
2.664.572
2.716.311
2.768.051
4.029.163
4.150.038
4.230.621
4.311.204
4.684.985
4.825.535
4.919.234
5.012.934
26.559.549
27.356.335
27.887.526
28.418.717
27.536.329
28.362.418
28.913.145
29.463.872
42.331.204
43.601.140
44.447.764
45.294.388
11.173.884
11.509.100
11.732.578
11.956.056
17.449.581
17.973.069
18.322.060
18.671.052
18.403.864
18.955.980
19.324.057
19.692.134
4.864.078
5.010.001
5.107.282
5.204.564
10.947.581
11.276.008
11.494.960
11.713.911
18.319.312
18.868.891
19.235.277
19.601.663

RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
424
K-4-17-i
425
K-4-17-ii
426
K-4-17-iii
427
K-4-18-i
428
K-4-18-ii
429
K-4-18-iii
430
L-1-20-i
431
L-1-20-ii
432
L-1-20-iii
433
L-1-30-i
434
L-1-30-ii
435
L-1-30-iii
436
L-1-40-i
437
L-1-40-ii
438
L-1-40-iii
439
L-1-50-i
7.981.346
8.220.786
8.380.413
8.540.040
440
L-1-50-ii
14.366.422
14.797.415
15.084.743
15.372.072
441
L-1-50-iii
17.371.037
17.892.168
18.239.589
18.587.010
442
L-4-10-i
3.554.935
3.661.583
3.732.682
3.803.780
443
L-4-10-ii
4.464.308
4.598.237
4.687.523
4.776.809
444
L-4-10-iii
9.188.035
9.463.676
9.647.437
9.831.197
445
L-4-11-i
3.682.187
3.792.652
3.866.296
3.939.940
- 154 No
Kode
INA-CBG
446
L-4-11-ii
447
L-4-11-iii
448
L-4-12-i
449
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.044.532
5.195.868
5.296.758
5.397.649
13.680.139
14.090.543
14.364.146
14.637.749
3.634.967
3.744.016
3.816.715
3.889.415
L-4-12-ii
5.712.117
5.883.481
5.997.723
6.111.965
450
L-4-12-iii
9.250.569
9.528.086
9.713.097
9.898.109
451
L-4-13-i
2.443.597
2.516.905
2.565.777
2.614.649
452
L-4-13-ii
2.817.611
2.902.140
2.958.492
3.014.844
453
L-4-13-iii
4.226.637
4.353.436
4.437.968
4.522.501
454
L-4-14-i
2.369.957
2.441.055
2.488.454
2.535.854
455
L-4-14-ii
3.554.935
3.661.583
3.732.682
3.803.780
456
L-4-14-iii
6.086.970
6.269.579
6.391.319
6.513.058
457
M-1-01-i
18.268.943
18.817.011
19.182.390
19.547.769
458
M-1-01-ii
20.391.095
21.002.828
21.410.650
21.818.472
459
M-1-01-iii
28.643.965
29.503.283
30.076.163
30.649.042
460
M-1-02-i
11.671.359
12.021.500
12.254.927
12.488.354
461
M-1-02-ii
19.162.152
19.737.017
20.120.260
20.503.503
462
M-1-02-iii
34.701.779
35.742.833
36.436.868
37.130.904
31.359.309
32.300.088
32.927.274
33.554.461
37.667.007
38.797.017
39.550.357
40.303.697
39.120.241
40.293.848
41.076.253
41.858.657
7.699.246
7.930.223
8.084.208
8.238.193
9.870.353
10.166.463
10.363.871
10.561.278
12.350.886
12.721.413
12.968.430
13.215.448
11.993.946
12.353.765
12.593.643
12.833.522
13.861.788
14.277.641
14.554.877
14.832.113
23.610.400
24.318.712
24.790.920
25.263.128
14.677.692
15.118.023
15.411.577
15.705.130
19.663.521
20.253.426
20.646.697
21.039.967
40.056.456
41.258.150
42.059.279
42.860.408
8.274.519
8.522.755
8.688.245
8.853.735
30.747.901
31.670.338
32.285.296
32.900.254
38.353.022
39.503.613
40.270.673
41.037.734
463
M-1-03-i
464
M-1-03-ii
465
M-1-03-iii
466
M-1-04-i
467
M-1-04-ii
468
M-1-04-iii
469
M-1-05-i
470
M-1-05-ii
471
M-1-05-iii
472
M-1-07-i
473
M-1-07-ii
474
M-1-07-iii
475
M-1-10-i
476
M-1-10-ii
477
M-1-10-iii


TULANG WAJAH RINGAN
TULANG WAJAH SEDANG
TULANG WAJAH BERAT
- 155 No
Kode
INA-CBG
478
M-1-20-i
479
M-1-20-ii
480
M-1-20-iii
481
M-1-30-i
482
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
8.185.637
8.431.206
8.594.919
8.758.632
11.674.411
12.024.643
12.258.131
12.491.620
22.711.659
23.393.009
23.847.242
24.301.475
4.896.235
5.043.122
5.141.047
5.238.971
M-1-30-ii
10.116.866
10.420.372
10.622.710
10.825.047
483
M-1-30-iii
PROSEDUR KAKI BERAT
15.092.231
15.544.998
15.846.843
16.148.688
484
M-1-40-i
5.484.624
5.649.162
5.758.855
5.868.547
485
M-1-40-ii
10.095.546
10.398.412
10.600.323
10.802.234
486
M-1-40-iii
17.667.205
18.197.222
18.550.566
18.903.910
487
M-1-50-i
6.552.029
6.748.590
6.879.630
7.010.671
488
M-1-50-ii
13.189.388
13.585.070
13.848.857
14.112.645
489
M-1-50-iii
20.191.092
20.796.825
21.200.646
21.604.468
4.944.714
5.093.056
5.191.950
5.290.844
9.899.350
10.196.331
10.394.318
10.592.305
17.228.371
17.745.222
18.089.789
18.434.357
6.623.929
6.822.647
6.955.125
7.087.604
13.516.095
13.921.578
14.191.900
14.462.222
21.789.579
22.443.266
22.879.057
23.314.849

SENDI MAYOR RINGAN
SENDI MAYOR SEDANG
SENDI MAYOR BERAT

RINGAN
SEDANG
BERAT

SELAIN KAKI (BERAT)
490
M-1-60-i
491
M-1-60-ii
492
M-1-60-iii
493
M-1-70-i
494
M-1-70-ii
495
M-1-70-iii
496
M-1-80-i
5.337.094
5.497.207
5.603.949
5.710.691
497
M-1-80-ii
8.068.595
8.310.653
8.472.024
8.633.396
498
M-1-80-iii
18.575.995
19.133.275
19.504.795
19.876.315
499
M-4-10-i
3.747.176
3.859.591
3.934.535
4.009.478
500
M-4-10-ii
5.620.764
5.789.387
5.901.802
6.014.217
501
M-4-10-iii
FRAKTUR FEMUR BERAT
10.950.827
11.279.352
11.498.369
11.717.385
502
M-4-11-i
4.683.970
4.824.489
4.918.168
5.011.848
503
M-4-11-ii
10.262.455
10.570.329
10.775.578
10.980.827
504
M-4-11-iii
18.215.618
18.762.086
19.126.399
19.490.711
505
M-4-12-i
3.747.176
3.859.591
3.934.535
4.009.478
506
M-4-12-ii
6.817.982
7.022.522
7.158.882
7.295.241
507
M-4-12-iii
12.316.814
12.686.319
12.932.655
13.178.991
508
M-4-13-i
6.239.861
6.427.056
6.551.854
6.676.651

PANGGUL RINGAN
PANGGUL SEDANG
PANGGUL BERAT
PELVIS RINGAN
PELVIS SEDANG
PELVIS BERAT
- 156 No
Kode
INA-CBG
509
M-4-13-ii
510
M-4-13-iii
511
M-4-14-i
512
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
9.367.940
9.648.978
9.836.337
10.023.696
18.562.022
19.118.883
19.490.123
19.861.363
7.104.401
7.317.533
7.459.621
7.601.709
M-4-14-ii
8.776.408
9.039.700
9.215.228
9.390.757
513
M-4-14-iii
OSTEOMIELITIS BERAT
13.146.113
13.540.497
13.803.419
14.066.341
514
M-4-15-i
4.217.572
4.344.099
4.428.451
4.512.802
515
M-4-15-ii
5.623.785
5.792.499
5.904.975
6.017.450
516
M-4-15-iii
15.925.498
16.403.263
16.721.773
17.040.283
517
M-4-16-i
4.683.970
4.824.489
4.918.168
5.011.848
518
M-4-16-ii
7.494.352
7.719.182
7.869.069
8.018.957
519
M-4-16-iii
12.569.902
12.946.999
13.198.397
13.449.795
4.683.970
4.824.489
4.918.168
5.011.848
6.557.558
6.754.285
6.885.436
7.016.587
9.157.978
9.432.717
9.615.877
9.799.036
4.952.421
5.100.994
5.200.042
5.299.091
7.494.352
7.719.182
7.869.069
8.018.957
8.399.018
8.650.988
8.818.968
8.986.949
3.682.192
3.792.658
3.866.302
3.939.946
6.201.991
6.388.051
6.512.091
6.636.130
12.112.947
12.476.336
12.718.595
12.960.854
3.747.176
3.859.591
3.934.535
4.009.478
5.620.764
5.789.387
5.901.802
6.014.217
6.229.131
6.416.005
6.540.588
6.665.170
3.747.176
3.859.591
3.934.535
4.009.478
4.683.970
4.824.489
4.918.168
5.011.848
10.754.126
11.076.750
11.291.832
11.506.915

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
RINGAN
SEDANG
BERAT
ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
520
M-4-17-i
521
M-4-17-ii
522
M-4-17-iii
523
M-4-18-i
524
M-4-18-ii
525
M-4-18-iii
526
M-4-19-i
527
M-4-19-ii
528
M-4-19-iii
529
M-4-20-i
530
M-4-20-ii
531
M-4-20-iii
532
M-4-21-i
533
M-4-21-ii
534
M-4-21-iii
535
N-1-01-i
6.412.461
6.604.835
6.733.084
6.861.334
536
N-1-01-ii
8.672.709
8.932.890
9.106.345
9.279.799
537
N-1-01-iii
18.388.723
18.940.385
19.308.160
19.675.934
9.688.074
9.978.716
10.172.477
10.366.239
13.102.901
13.495.988
13.758.046
14.020.104
538
N-1-11-i
539
N-1-11-ii

RINGAN
SEDANG
- 157 No
Kode
INA-CBG
540
N-1-11-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
25.540.306
26.306.515
26.817.322
27.328.128
4.788.807
4.932.472
5.028.248
5.124.024
12.200.676
12.566.696
12.810.709
13.054.723
22.236.491
22.903.586
23.348.316
23.793.046
541
N-1-12-i
542
N-1-12-ii
543
N-1-12-iii
544
N-1-20-i
7.100.474
7.313.489
7.455.498
7.597.508
545
N-1-20-ii
14.077.716
14.500.048
14.781.602
15.063.156
546
N-1-20-iii
16.103.631
16.586.740
16.908.813
17.230.886
8.447.267
8.700.685
8.869.631
9.038.576
12.836.677
13.221.777
13.478.510
13.735.244
14.777.131
15.220.445
15.515.988
15.811.531
7.611.815
7.840.169
7.992.405
8.144.642
10.318.086
10.627.629
10.833.991
11.040.353
12.000.233
12.360.240
12.600.244
12.840.249
2.962.446
3.051.319
3.110.568
3.169.817
4.344.169
4.474.494
4.561.377
4.648.261
8.682.606
8.943.084
9.116.736
9.290.388

URIN BAWAH RINGAN
URIN BAWAH SEDANG
URIN BAWAH BERAT
RINGAN
SEDANG
BERAT
GINJAL RINGAN
GINJAL SEDANG
GINJAL BERAT
547
N-1-30-i
548
N-1-30-ii
549
N-1-30-iii
550
N-1-40-i
551
N-1-40-ii
552
N-1-40-iii
553
N-4-10-i
554
N-4-10-ii
555
N-4-10-iii
556
N-4-11-i
2.484.473
2.559.007
2.608.696
2.658.386
557
N-4-11-ii
4.198.699
4.324.660
4.408.634
4.492.608
558
N-4-11-iii
4.804.682
4.948.823
5.044.916
5.141.010
559
N-4-12-i
2.402.370
2.474.441
2.522.488
2.570.535
560
N-4-12-ii
3.554.935
3.661.583
3.732.682
3.803.780
561
N-4-12-iii
5.902.360
6.079.431
6.197.478
6.315.526
562
N-4-13-i
BATU URIN RINGAN
3.424.152
3.526.877
3.595.360
3.663.843
563
N-4-13-ii
BATU URIN SEDANG
4.128.240
4.252.087
4.334.652
4.417.217
564
N-4-13-iii
BATU URIN BERAT
10.166.722
10.471.724
10.675.058
10.878.393
2.052.822
2.114.406
2.155.463
2.196.519
3.161.087
3.255.920
3.319.141
3.382.363
5.126.276
5.280.064
5.382.589
5.485.115
3.335.249
3.435.306
3.502.011
3.568.716
565
N-4-14-i
566
N-4-14-ii
567
N-4-14-iii
568
N-4-15-i

(RINGAN)
(SEDANG)
(BERAT)
SALURAN URIN RINGAN
- 158 No
Kode
INA-CBG
569
N-4-15-ii
570
N-4-15-iii
571
N-4-16-i
572
N-4-16-ii
573
N-4-16-iii
574
O-6-10-i
575
O-6-10-ii
576
O-6-10-iii
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
584
585
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.576.999
4.714.309
4.805.849
4.897.389
5.223.182
5.379.878
5.484.341
5.588.805
3.349.651
3.450.141
3.517.134
3.584.127
4.739.913
4.882.111
4.976.909
5.071.707
9.967.332
10.266.352
10.465.699
10.665.045
4.166.346
4.291.337
4.374.663
4.457.990
4.625.279
4.764.038
4.856.543
4.949.049
5.699.911
5.870.908
5.984.907
6.098.905
2.630.270
2.709.178
2.761.783
2.814.389
4.285.481
4.414.045
4.499.755
4.585.464
7.262.560
7.480.437
7.625.688
7.770.939
2.908.872
2.996.138
3.054.315
3.112.493
3.493.548
3.598.354
3.668.225
3.738.096
4.389.142
4.520.816
4.608.599
4.696.382
2.150.934
2.215.462
2.258.480
2.301.499
O-6-13-ii
2.408.092
2.480.335
2.528.497
2.576.658
O-6-13-iii
2.994.781
3.084.625
3.144.520
3.204.416
59.547.146
61.333.560
62.524.503
63.715.446
73.680.278
75.890.687
77.364.292
78.837.898
86.479.992
89.074.392
90.803.992
92.533.592
79.009.444
81.379.728
82.959.916
84.540.105
90.631.965
93.350.924
95.163.563
96.976.203
103.553.501
106.660.106
108.731.176
110.802.246
3.990.673
4.110.393
4.190.206
4.270.020
5.586.942
5.754.550
5.866.289
5.978.028
8.800.701
9.064.722
9.240.736
9.416.750
39.029.987
40.200.886
40.981.486
41.762.086
50.652.508
52.172.083
53.185.133
54.198.183
72.622.946
74.801.635
76.254.094
77.706.553
586
P-8-01-i
587
P-8-01-ii
588
P-8-01-iii
589
P-8-02-i
590
P-8-02-ii
591
P-8-02-iii
592
P-8-03-i
593
P-8-03-ii
594
P-8-03-iii
595
P-8-04-i
596
P-8-04-ii
597
P-8-04-iii

SALURAN URIN SEDANG
SALURAN URIN BERAT
RINGAN
SEDANG
BERAT
&KURET RINGAN
KURET SEDANG
KURET BERAT

- 159 No
Kode
INA-CBG
598
P-8-05-i
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii
603
P-8-06-iii
604
P-8-07-i
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
614
P-8-11-ii
615
P-8-11-iii
616
P-8-12-i
617
P-8-12-ii
618
P-8-12-iii
619
P-8-13-i
620
P-8-13-ii
621
P-8-13-iii
622
P-8-14-i
623
P-8-14-ii
624
P-8-14-iii
625
P-8-15-i
Deskripsi (INA-CBG)
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
RINGAN
SEDANG
BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
ASPIRASI RINGAN
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
21.223.241
21.859.938
22.284.403
22.708.868
30.081.083
30.983.516
31.585.138
32.186.759
44.320.438
45.650.051
46.536.460
47.422.869
3.192.538
3.288.314
3.352.165
3.416.016
8.797.487
9.061.412
9.237.361
9.413.311
16.364.329
16.855.259
17.182.546
17.509.832
5.640.065
5.809.266
5.922.068
6.034.869
15.664.440
16.134.374
16.447.662
16.760.951
20.751.499
21.374.044
21.789.074
22.204.104
4.433.923
4.566.941
4.655.619
4.744.298
6.294.578
6.483.415
6.609.307
6.735.198
8.886.011
9.152.591
9.330.311
9.508.032
2.750.801
2.833.325
2.888.341
2.943.357
3.984.935
4.104.483
4.184.182
4.263.881
7.823.603
8.058.311
8.214.783
8.371.255
3.332.092
3.432.055
3.498.697
3.565.339
16.494.054
16.988.876
17.318.757
17.648.638
16.839.607
17.344.796
17.681.588
18.018.380
3.655.032
3.764.682
3.837.783
3.910.884
5.682.939
5.853.428
5.967.086
6.080.745
6.704.667
6.905.807
7.039.900
7.173.993
1.889.117
1.945.791
1.983.573
2.021.356
3.495.797
3.600.671
3.670.587
3.740.503
5.228.338
5.385.188
5.489.755
5.594.322
3.451.614
3.555.162
3.624.194
3.693.227
7.047.218
7.258.635
7.399.579
7.540.524
7.730.773
7.962.696
8.117.311
8.271.927
2.595.721
2.673.593
2.725.507
2.777.422
- 160 No
Kode
INA-CBG
626
P-8-15-ii
627
P-8-15-iii
628
P-8-16-i
629
P-8-16-ii
630
P-8-16-iii
631
P-8-17-i
632
P-8-17-ii
633
P-8-17-iii
634
S-4-10-i
635
S-4-10-ii
636
S-4-10-iii
637
S-4-11-i
638
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.188.164
5.343.809
5.447.572
5.551.336
6.094.302
6.277.131
6.399.017
6.520.903
2.349.741
2.420.233
2.467.228
2.514.223
3.333.208
3.433.204
3.499.869
3.566.533
4.326.668
4.456.468
4.543.002
4.629.535
1.548.009
1.594.449
1.625.409
1.656.369
5.151.313
5.305.852
5.408.879
5.511.905
10.397.597
10.709.525
10.917.477
11.125.429
2.369.957
2.441.055
2.488.454
2.535.854
2.962.446
3.051.319
3.110.568
3.169.817
3.850.671
3.966.191
4.043.204
4.120.218
1.481.223
1.525.660
1.555.284
1.584.908
S-4-11-ii
2.369.957
2.441.055
2.488.454
2.535.854
639
S-4-11-iii
3.647.304
3.756.723
3.829.670
3.902.616
640
S-4-12-i
1.777.467
1.830.791
1.866.341
1.901.890
641
S-4-12-ii
2.369.957
2.441.055
2.488.454
2.535.854
642
S-4-12-iii
4.628.713
4.767.574
4.860.148
4.952.723
2.369.957
2.441.055
2.488.454
2.535.854
4.189.552
4.315.238
4.399.029
4.482.820
8.530.460
8.786.374
8.956.983
9.127.592
1.443.971
1.487.290
1.516.170
1.545.049
3.067.479
3.159.503
3.220.853
3.282.202
5.817.032
5.991.543
6.107.884
6.224.225
1.092.089
1.124.851
1.146.693
1.168.535
2.061.143
2.122.977
2.164.200
2.205.423
2.669.659
2.749.749
2.803.142
2.856.535

ASPIRASI SEDANG
ASPIRASI BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT

PASIEN RINGAN
PASIEN SEDANG
PASIEN BERAT
643
S-4-13-i
644
S-4-13-ii
645
S-4-13-iii
646
S-4-14-i
647
S-4-14-ii
648
S-4-14-iii
649
S-4-15-i
650
S-4-15-ii
651
S-4-15-iii
652
S-4-16-i
LUKA BAKAR RINGAN
4.147.424
4.271.847
4.354.795
4.437.744
653
S-4-16-ii
LUKA BAKAR SEDANG
6.414.754
6.607.196
6.735.491
6.863.786
654
S-4-16-iii
11.454.538
11.798.174
12.027.265
12.256.356
2.421.872
2.494.528
2.542.966
2.591.403
2.962.446
3.051.319
3.110.568
3.169.817
4.830.852
4.975.778
5.072.395
5.169.012
655
S-4-17-i
656
S-4-17-ii
657
S-4-17-iii
LUKA BAKAR BERAT

- 161 No
Kode
INA-CBG
658
T-1-10-i
659
T-1-10-ii
660
T-1-10-iii
661
T-4-10-i
662
T-4-10-ii
663
T-4-10-iii
664
T-4-11-i
665
T-4-11-ii
666
T-4-11-iii
667
T-4-12-i
668
T-4-12-ii
669
T-4-12-iii
670
U-1-10-i
671
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.500.040
2.575.042
2.625.042
2.675.043
3.357.385
3.458.106
3.525.254
3.592.402
6.108.177
6.291.422
6.413.586
6.535.750
998.591
1.028.548
1.048.520
1.068.492
1.903.092
1.960.185
1.998.247
2.036.309
2.766.580
2.849.577
2.904.909
2.960.240
1.081.497
1.113.942
1.135.572
1.157.202
1.701.968
1.753.027
1.787.067
1.821.106
2.741.370
2.823.611
2.878.438
2.933.265
2.073.712
2.135.923
2.177.398
2.218.872
3.134.302
3.228.331
3.291.017
3.353.703
4.875.847
5.022.122
5.119.639
5.217.156
2.207.276
2.273.495
2.317.640
2.361.786
U-1-10-ii
4.504.083
4.639.206
4.729.287
4.819.369
672
U-1-10-iii
19.449.541
20.033.027
20.422.018
20.811.009
673
U-1-11-i
674
U-1-11-ii
675
U-1-11-iii
676

DOKTER RINGAN
DOKTER SEDANG
DOKTER BERAT

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
9.577.615
9.864.943
10.056.496
10.248.048
12.770.153
13.153.258
13.408.661
13.664.064
23.496.061
24.200.943
24.670.864
25.140.785
U-1-12-i
6.409.793
6.602.087
6.730.282
6.858.478
677
U-1-12-ii
14.366.422
14.797.415
15.084.743
15.372.072
678
U-1-12-iii
18.655.071
19.214.723
19.587.825
19.960.926
679
U-1-13-i
6.385.077
6.576.629
6.704.330
6.832.032
680
U-1-13-ii
7.889.443
8.126.126
8.283.915
8.441.704
681
U-1-13-iii
13.891.534
14.308.280
14.586.111
14.863.942
3.858.244
3.973.992
4.051.156
4.128.321
4.734.842
4.876.887
4.971.584
5.066.280
5.610.921
5.779.248
5.891.467
6.003.685

682
U-1-14-i
683
U-1-14-ii
684
U-1-14-iii
685
U-1-15-i
2.266.094
2.334.077
2.379.399
2.424.721
686
U-1-15-ii
3.219.961
3.316.560
3.380.959
3.445.359
687
U-1-15-iii
6.345.063
6.535.415
6.662.316
6.789.218
U-1-20-i

5.861.398
6.037.240
6.154.468
6.271.696
688
- 162 No
Kode
INA-CBG
689
U-1-20-ii
690
U-1-20-iii
691
U-1-30-i
692
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
10.433.289
10.746.287
10.954.953
11.163.619
23.503.370
24.208.471
24.678.538
25.148.606
5.028.057
5.178.899
5.279.460
5.380.021
U-1-30-ii
6.787.877
6.991.514
7.127.271
7.263.029
693
U-1-30-iii
12.770.153
13.153.258
13.408.661
13.664.064
694
U-4-10-i
4.680.282
4.820.690
4.914.296
5.007.901
695
U-4-10-ii
11.732.483
12.084.458
12.319.107
12.553.757
696
U-4-10-iii
17.115.138
17.628.592
17.970.895
18.313.197
697
U-4-11-i
2.369.957
2.441.055
2.488.454
2.535.854
698
U-4-11-ii
3.554.935
3.661.583
3.732.682
3.803.780
699
U-4-11-iii
5.384.176
5.545.701
5.653.385
5.761.068
700
U-4-12-i
2.369.957
2.441.055
2.488.454
2.535.854
701
U-4-12-ii
3.025.658
3.116.427
3.176.941
3.237.454
702
U-4-12-iii
4.810.658
4.954.978
5.051.191
5.147.404
703
U-4-13-i
2.369.957
2.441.055
2.488.454
2.535.854
704
U-4-13-ii
2.706.794
2.787.997
2.842.133
2.896.269
705
U-4-13-iii
3.365.743
3.466.715
3.534.030
3.601.345
706
U-4-14-i
2.962.446
3.051.319
3.110.568
3.169.817
707
U-4-14-ii
3.554.935
3.661.583
3.732.682
3.803.780
708
U-4-14-iii
5.955.133
6.133.787
6.252.889
6.371.992
709
U-4-15-i
2.369.957
2.441.055
2.488.454
2.535.854
710
U-4-15-ii
2.962.446
3.051.319
3.110.568
3.169.817
711
U-4-15-iii
4.148.228
4.272.675
4.355.639
4.438.604
712
V-1-10-i
6.928.169
7.136.014
7.274.577
7.413.141
713
V-1-10-ii
7.981.346
8.220.786
8.380.413
8.540.040
714
V-1-10-iii
15.164.557
15.619.494
15.922.785
16.226.076
715
V-1-11-i
7.981.346
8.220.786
8.380.413
8.540.040
716
V-1-11-ii
8.907.316
9.174.535
9.352.681
9.530.828
717
V-1-11-iii
13.190.371
13.586.082
13.849.889
14.113.697
4.720.644
4.862.263
4.956.676
5.051.089
17.699.782
18.230.776
18.584.772
18.938.767
19.905.726
20.502.898
20.901.013
21.299.127
7.154.966
7.369.615
7.512.714
7.655.813
718
V-1-12-i
719
V-1-12-ii
720
V-1-12-iii
721
V-1-13-i


DAN TELINGA RINGAN
DAN TELINGA SEDANG
DAN TELINGA BERAT


KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

- 163 No
Kode
INA-CBG
722
V-1-13-ii
723
V-1-13-iii
724
V-1-14-i
725
V-1-14-ii
726
V-1-14-iii
727
V-1-15-i
728
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
13.596.488
14.004.382
14.276.312
14.548.242
19.155.230
19.729.887
20.112.991
20.496.096
8.625.394
8.884.156
9.056.664
9.229.172
12.544.897
12.921.244
13.172.142
13.423.039
17.052.962
17.564.551
17.905.610
18.246.670
4.066.393
4.188.385
4.269.713
4.351.041
V-1-15-ii
7.473.248
7.697.446
7.846.911
7.996.376
729
V-1-15-iii
12.433.902
12.806.919
13.055.597
13.304.275
730
V-4-10-i
6.547.919
6.744.357
6.875.315
7.006.274
731
V-4-10-ii
8.457.420
8.711.143
8.880.291
9.049.439
732
V-4-10-iii
16.163.614
16.648.523
16.971.795
17.295.067
733
V-4-11-i
3.329.862
3.429.758
3.496.355
3.562.953
734
V-4-11-ii
4.865.461
5.011.425
5.108.734
5.206.043
735
V-4-11-iii
8.027.688
8.268.519
8.429.072
8.589.626
736
W-1-01-i
9.791.426
10.085.168
10.280.997
10.476.825
737
W-1-01-ii
11.793.308
12.147.107
12.382.973
12.618.839
738
W-1-01-iii
26.049.074
26.830.546
27.351.528
27.872.509
739
W-1-10-i
2.726.900
2.808.707
2.863.245
2.917.783
740
W-1-10-ii
5.088.843
5.241.509
5.343.285
5.445.062
741
W-1-10-iii
8.323.733
8.573.445
8.739.920
8.906.394
742
W-1-11-i
2.832.342
2.917.313
2.973.960
3.030.606
743
W-1-11-ii
5.462.531
5.626.407
5.735.658
5.844.908
744
W-1-11-iii
9.577.615
9.864.943
10.056.496
10.248.048
745
W-1-12-i
2.573.609
2.650.817
2.702.289
2.753.761
746
W-1-12-ii
2.926.144
3.013.928
3.072.451
3.130.974
747
W-1-12-iii
4.494.926
4.629.774
4.719.672
4.809.571
748
W-1-13-i
2.797.107
2.881.020
2.936.962
2.992.905
749
W-1-13-ii
3.036.852
3.127.958
3.188.695
3.249.432
750
W-1-13-iii
4.079.053
4.201.424
4.283.006
4.364.587
751
W-1-20-i
8.346.355
8.596.746
8.763.673
8.930.600
752
W-1-20-ii
11.740.401
12.092.613
12.327.421
12.562.229
753
W-1-20-iii
14.366.422
14.797.415
15.084.743
15.372.072

NON KOMPLEK (BERAT)

RINGAN
SEDANG
BERAT

SERVIK RINGAN
SERVIK SEDANG
SERVIK BERAT
ENDOSKOP RINGAN
ENDOSKOP SEDANG
ENDOSKOP BERAT
- 164 No
Kode
INA-CBG
754
W-1-30-i
755
W-1-30-ii
756
W-1-30-iii
757
W-4-10-i
758
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.556.273
4.692.961
4.784.087
4.875.212
7.267.491
7.485.516
7.630.865
7.776.215
19.326.047
19.905.828
20.292.349
20.678.870
3.397.838
3.499.773
3.567.730
3.635.687
W-4-10-ii
4.592.559
4.730.336
4.822.187
4.914.038
759
W-4-10-iii
9.479.826
9.764.221
9.953.818
10.143.414
760
W-4-11-i
2.962.446
3.051.319
3.110.568
3.169.817
761
W-4-11-ii
4.739.913
4.882.111
4.976.909
5.071.707
762
W-4-11-iii
5.760.399
5.933.211
6.048.419
6.163.627
763
W-4-12-i
2.369.957
2.441.055
2.488.454
2.535.854
764
W-4-12-ii
3.297.843
3.396.778
3.462.735
3.528.692
765
W-4-12-iii
3.978.701
4.098.062
4.177.637
4.257.211
766
W-4-13-i
ABORTUS RINGAN
1.299.712
1.338.703
1.364.698
1.390.692
767
W-4-13-ii
ABORTUS SEDANG
1.777.467
1.830.791
1.866.341
1.901.890
768
W-4-13-iii
ABORTUS BERAT
2.369.957
2.441.055
2.488.454
2.535.854
769
W-4-14-i
1.777.467
1.830.791
1.866.341
1.901.890
770
W-4-14-ii
2.369.957
2.441.055
2.488.454
2.535.854
771
W-4-14-iii
2.876.626
2.962.925
3.020.457
3.077.990
772
W-4-15-i
1.623.206
1.671.903
1.704.367
1.736.831
773
W-4-15-ii
1.805.315
1.859.474
1.895.580
1.931.687
774
W-4-15-iii
2.416.913
2.489.420
2.537.758
2.586.096
775
W-4-16-i
1.777.467
1.830.791
1.866.341
1.901.890
776
W-4-16-ii
2.580.097
2.657.500
2.709.102
2.760.704
777
W-4-16-iii
3.288.278
3.386.926
3.452.691
3.518.457
778
W-4-17-i
1.589.866
1.637.562
1.669.359
1.701.157
779
W-4-17-ii
2.369.957
2.441.055
2.488.454
2.535.854
780
W-4-17-iii
4.483.486
4.617.991
4.707.661
4.797.330
781
Z-4-10-i
REHABILITASI RINGAN
4.066.565
4.188.562
4.269.893
4.351.224
782
Z-4-10-ii
REHABILITASI SEDANG
5.397.778
5.559.711
5.667.667
5.775.622
783
Z-4-10-iii
REHABILITASI BERAT
7.668.058
7.898.100
8.051.461
8.204.822
784
Z-4-11-i
3.887.352
4.003.972
4.081.720
4.159.467
785
Z-4-11-ii
4.679.513
4.819.898
4.913.488
5.007.078
786
Z-4-11-iii
7.315.774
7.535.247
7.681.563
7.827.878
787
Z-4-12-i

1.777.467
1.830.791
1.866.341
1.901.890

RINGAN
SEDANG
BERAT

- 165 No
Kode
INA-CBG
788
Z-4-12-ii
789
Z-4-12-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.966.057
4.085.038
4.164.359
4.243.681
5.040.230
5.191.437
5.292.241
5.393.046
- 166 b. RawatJalan
No
Kode
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0

C-3-10-0
10
C-3-11-0
11
C-3-12-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.474.418
1.518.650
1.548.139
1.577.627
1.912.551
1.969.927
2.008.178
2.046.429
3.556.640
3.663.339
3.734.472
3.805.604
2.939.218
3.027.394
3.086.178
3.144.963
2.455.463
2.529.127
2.578.236
2.627.345
860.896
886.723
903.941
921.159
1.919.686
1.977.276
2.015.670
2.054.064
394.432
406.265
414.154
422.043
1.075.955
1.108.234
1.129.753
1.151.272

KANDUNG KEMIH
1.701.664
1.752.714
1.786.747
1.820.781
385.764
397.337
405.052
412.767
374.603
385.841
393.333
400.825
3.189.001
3.284.671
3.348.451
3.412.231
2.922.847
3.010.532
3.068.989
3.127.446

LAPAROSKOPI
PANKREAS
LAPAROSKOPI
EMPEDU

OVARIUM
GASTROINTESTINAL
GINJAL ATAU PROSTAT
12
C-3-13-0
13
C-3-14-0
14
C-3-15-0
15
C-3-16-0
662.831
682.716
695.973
709.230
16
C-3-17-0

LEHER
439.703
452.894
461.688
470.482
17
C-3-18-0
194.945
200.794
204.692
208.591
18
C-3-19-0

MYELOMA ATAU TESTIS
275.692
283.963
289.477
294.991
19
C-3-20-0
5.490.419
5.655.132
5.764.940
5.874.749
20
C-3-21-0
314.614
324.052
330.345
336.637
21
C-3-22-0
1.381.323
1.422.763
1.450.389
1.478.016
22
C-3-23-0
223.744
230.457
234.931
239.406
23
D-2-10-0

TULANG
1.895.592
1.952.460
1.990.372
2.028.284
24
D-2-11-0
PROSEDUR LIMPA
2.373.606
2.444.814
2.492.286
2.539.758
25
D-2-21-0
1.990.783
2.050.506
2.090.322
2.130.138
26
D-2-22-0
436.917
450.025
458.763
467.501
27
D-3-10-0
316.470
325.964
332.293
338.623
28
D-3-11-0
821.647
846.296
862.729
879.162
29
E-2-10-0
487.395
502.016
511.764
521.512
30
E-2-21-0
353.344
363.945
371.012
378.078
31
E-2-22-0
353.344
363.945
371.012
378.078

TYMUS
TYMUS
TULANG
PEMBENTUK DARAH
PARATIROID
THYROGLOSSAL
- 167 No
Kode
INA-CBG
32
E-3-10-0
33
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

ENDOKRIN
410.917
423.244
431.462
439.681
F-3-10-0
TERAPI SHOCK
573.215
590.412
601.876
613.341
34
F-5-10-0
702.374
723.446
737.493
751.541
35
F-5-11-0
TERAPI KELOMPOK
463.151
477.046
486.309
495.572
36
F-5-12-0
592.681
610.461
622.315
634.168
37
F-5-13-0
501.961
517.020
527.059
537.098
38
F-5-14-0
336.749
346.851
353.586
360.321
39
F-5-15-0
315.914
325.391
331.709
338.028
40
F-5-16-0
329.054
338.926
345.507
352.088
41
G-2-10-0
277.089
285.402
290.944
296.485
42
G-2-11-0
2.401.926
2.473.984
2.522.022
2.570.061
43
G-2-12-0

EKSTRAKRANIAL
3.480.982
3.585.411
3.655.031
3.724.651
44
G-2-13-0
1.063.163
1.095.057
1.116.321
1.137.584
45
G-2-21-0
1.557.484
1.604.208
1.635.358
1.666.508
46
G-2-22-0
1.413.549
1.455.955
1.484.226
1.512.497
47
G-2-31-0
2.903.879
2.990.996
3.049.073
3.107.151
48
G-2-32-0
1.488.526
1.533.182
1.562.952
1.592.723
49
G-3-10-0
590.806
608.530
620.346
632.162
50
G-3-11-0
632.012
650.972
663.613
676.253
51
G-3-12-0
1.035.563
1.066.629
1.087.341
1.108.052
52
G-3-13-0
1.035.681
1.066.751
1.087.465
1.108.178
53
H-2-21-0
1.359.177
1.399.952
1.427.136
1.454.320
54
H-2-22-0
353.344
363.945
371.012
378.078
55
H-2-23-0
353.344
363.945
371.012
378.078
56
H-2-31-0
2.251.364
2.318.905
2.363.932
2.408.959
57
H-2-32-0
234.314
241.344
246.030
250.716
58
H-2-33-0
353.344
363.945
371.012
378.078
59
H-2-34-0
1.010.017
1.040.317
1.060.517
1.080.718
60
H-2-35-0
332.823
342.808
349.465
356.121
61
H-2-36-0
1.796.503
1.850.398
1.886.328
1.922.258
62
H-2-37-0

1.912.456
1.969.830
2.008.079
2.046.328
63
H-3-10-0
665.395
685.357
698.665
711.973
64
H-3-11-0
349.924
360.422
367.420
374.419

AKUT
MENTAL
PROSEDUR KRANIOTOMI

MATA
MATA
MATA
MATA
MATA
- 168 No
Kode
INA-CBG
65
H-3-12-0
66
H-3-13-0
67
I-2-11-0
68
I-2-12-0
69
I-2-13-0
70
I-2-14-0
71
I-2-15-0
Deskripsi (INA-CBG)
MATA
TORASIK
ABDOMEN
PENGGANTIAN ALAT
DARAH VENA
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
365.339
376.299
383.605
390.912
354.722
365.364
372.458
379.552
4.090.697
4.213.418
4.295.232
4.377.046
2.876.207
2.962.493
3.020.017
3.077.541
3.655.485
3.765.150
3.838.260
3.911.369
6.469.431
6.663.514
6.792.902
6.922.291
389.059
400.731
408.512
416.293
4.086.264
4.208.852
4.290.577
4.372.302
1.347.124
1.387.538
1.414.480
1.441.423
72
I-2-16-0
73
I-2-17-0
74
I-2-21-0
3.154.015
3.248.635
3.311.716
3.374.796
75
I-2-22-0
2.970.057
3.059.159
3.118.560
3.177.961
76
I-2-23-0
607.813
626.048
638.204
650.360
77
I-2-31-0
4.727.170
4.868.985
4.963.528
5.058.072
78
I-2-32-0
6.181.469
6.366.913
6.490.542
6.614.171
79
I-2-41-0
4.144.751
4.269.093
4.351.988
4.434.883
80
I-2-42-0

LAIN
4.818.958
4.963.527
5.059.906
5.156.286
81
I-3-10-0
PROSEDUR RESUSITASI
611.724
630.076
642.310
654.545
82
I-3-11-0
322.867
332.553
339.010
345.467
83
I-3-12-0
1.876.378
1.932.670
1.970.197
2.007.725
84
I-3-13-0
616.275
634.764
647.089
659.415
85
I-3-14-0
395.011
406.862
414.762
422.662

PACU JANTUNG

KARDIOVASKULAR
PERNAFASAN
PENDEK
349.924
360.422
367.420
374.419
2.166.505
2.231.500
2.274.830
2.318.160
349.240
359.717
366.702
373.687
86
I-3-15-0
87
J-2-10-0
88
J-2-21-0
89
J-2-22-0
1.759.952
1.812.751
1.847.950
1.883.149
90
J-2-31-0
PROSEDUR
2.282.815
2.351.300
2.396.956
2.442.613
91
J-2-32-0
1.698.794
1.749.757
1.783.733
1.817.709
92
J-3-10-0
353.344
363.945
371.012
378.078
93
J-3-11-0

PADA DADA
998.488
1.028.443
1.048.413
1.068.382
94
J-3-12-0
385.764
397.337
405.052
412.767
95
J-3-13-0
567.748
584.780
596.135
607.490
96
J-3-14-0
602.726
620.808
632.863
644.917
- 169 No
Kode
INA-CBG
97
J-3-15-0
98
J-3-16-0
99
J-3-17-0
100
K-2-10-0
101
K-2-11-0
102
K-2-12-0
103
K-2-13-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
528.543
544.399
554.970
565.541
602.726
620.808
632.863
644.917
353.344
363.945
371.012
378.078
1.017.046
1.047.557
1.067.898
1.088.239
2.171.808
2.236.962
2.280.398
2.323.834

1.667.143
1.717.157
1.750.500
1.783.843
2.713.365
2.794.766
2.849.033
2.903.301
353.344
363.945
371.012
378.078

PERNAFASAN
KECIL

FEMORALIS
USUS BESAR
ATAS
ATAS
353.344
363.945
371.012
378.078
4.541.316
4.677.556
4.768.382
4.859.208
1.527.014
1.572.824
1.603.364
1.633.905
353.344
363.945
371.012
378.078
1.682.037
1.732.498
1.766.139
1.799.780
480.579
494.996
504.608
514.219
1.114.620
1.148.058
1.170.351
1.192.643
104
K-2-14-0
105
K-2-21-0
106
K-2-22-0
107
K-2-31-0
108
K-2-32-0
109
K-2-41-0
110
K-2-42-0

111
K-2-51-0
112
K-2-52-0
607.813
626.048
638.204
650.360
113
K-2-53-0
353.344
363.945
371.012
378.078
114
K-3-10-0

GASTROINTESTINAL
672.391
692.562
706.010
719.458
115
K-3-11-0
404.238
416.365
424.450
432.535
116
K-3-12-0
409.948
422.247
430.446
438.645
117
K-3-13-0
353.344
363.945
371.012
378.078
946.971
975.380
994.319
1.013.259
457.305
471.024
480.170
489.317

GASTROINTESTINAL
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
605.959
624.137
636.257
648.376
2.083.308
2.145.807
2.187.473
2.229.139
1.335.386
1.375.447
1.402.155
1.428.863
602.726
620.808
632.863
644.917
607.813
626.048
638.204
650.360
1.820.025
1.874.626
1.911.026
1.947.427
408.202
420.448
428.612
436.777
118
K-3-14-0
119
K-3-15-0
120
K-3-16-0
121
L-2-21-0
122
L-2-22-0
123
L-2-31-0
124
L-2-32-0
125
L-2-41-0
126
L-2-42-0

127
L-2-51-0
2.724.863
2.806.609
2.861.106
2.915.603
L-2-52-0

2.084.610
2.147.148
2.188.840
2.230.532
128
- 170 No
Kode
INA-CBG
129
L-2-53-0
130
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

353.344
363.945
371.012
378.078
L-3-10-0
480.579
494.996
504.608
514.219
131
L-3-11-0
466.675
480.675
490.009
499.342
132
L-3-12-0
355.418
366.080
373.189
380.297
133
M-2-10-0
2.787.733
2.871.365
2.927.120
2.982.874
134
M-2-21-0
3.108.216
3.201.462
3.263.627
3.325.791
135
M-2-22-0
756.713
779.414
794.548
809.683
136
M-2-31-0
PROSEDUR BUNION
1.887.929
1.944.567
1.982.325
2.020.084
137
M-2-32-0
598.309
616.258
628.224
640.191
138
M-2-41-0

TULANG
598.309
616.258
628.224
640.191
139
M-2-42-0
206.194
212.380
216.503
220.627
140
M-2-51-0
439.905
453.102
461.900
470.698
141
M-2-52-0
439.905
453.102
461.900
470.698
142
M-2-61-0
PROSEDUR ARTROSKOPI
2.156.205
2.220.891
2.264.015
2.307.139
143
M-2-62-0
439.905
453.102
461.900
470.698
2.167.869
2.232.905
2.276.263
2.319.620
2.956.526
3.045.222
3.104.352
3.163.483
439.905
453.102
461.900
470.698
2.182.693
2.248.174
2.291.828
2.335.482
2.106.392
2.169.584
2.211.712
2.253.840

DAN WAJAH
PAHA
PAHA

TULANG
WAJAH
WAJAH
BAWAH
BAWAH
144
M-2-63-0
145
M-2-64-0
146
M-2-65-0
147
M-2-71-0
148
M-2-72-0
149
M-2-81-0
3.141.079
3.235.311
3.298.133
3.360.955
150
M-2-82-0
2.281.792
2.350.246
2.395.882
2.441.518
151
M-2-83-0
439.905
453.102
461.900
470.698
152
M-2-84-0
439.905
453.102
461.900
470.698
153
M-3-10-0
1.255.574
1.293.241
1.318.353
1.343.464
154
M-3-11-0
696.139
717.023
730.946
744.869
155
M-3-12-0
1.574.266
1.621.494
1.652.979
1.684.464
156
M-3-13-0
513.253
528.651
538.916
549.181
157
M-3-14-0

TERTUTUP
877.236
903.553
921.098
938.643
158
M-3-15-0
386.476
398.071
405.800
413.530
159
M-3-16-0

439.905
453.102
461.900
470.698
160
M-3-17-0
480.266
494.674
504.280
513.885
161
N-2-11-0
4.668.025
4.808.066
4.901.427
4.994.787

PERGELANGAN TANGAN
PERGELANGAN TANGAN
MUSKULOSKELETAL
SKELETAL
- 171 No
Kode
INA-CBG
162
N-2-12-0
163
N-2-21-0
164
N-2-22-0
165
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.700.407
2.781.419
2.835.427
2.889.435
2.686.173
2.766.758
2.820.481
2.874.205
607.813
626.048
638.204
650.360
N-2-23-0
607.813
626.048
638.204
650.360
166
N-2-24-0
1.964.249
2.023.176
2.062.461
2.101.746
167
N-2-31-0
1.653.579
1.703.186
1.736.258
1.769.330
168
N-2-32-0
607.813
626.048
638.204
650.360
169
N-2-41-0
607.813
626.048
638.204
650.360
170
N-2-42-0
1.027.929
1.058.767
1.079.325
1.099.884
171
N-3-10-0
607.813
626.048
638.204
650.360
172
N-3-11-0
704.239
725.366
739.451
753.535
173
N-3-12-0
544.196
560.522
571.406
582.290
174
N-3-13-0
607.813
626.048
638.204
650.360
175
N-3-14-0
522.990
538.680
549.140
559.600
176
N-3-15-0
1.341.079
1.381.311
1.408.133
1.434.954
177
O-7-10-0
223.902
230.619
235.097
239.575
178
O-7-11-0
1.233.090
1.270.082
1.294.744
1.319.406
179
O-7-12-0
449.009
462.480
471.460
480.440
180
O-7-13-0
249.540
257.026
262.017
267.007
181
P-9-10-0
332.823
342.808
349.465
356.121
182
P-9-11-0
332.823
342.808
349.465
356.121
183
P-9-12-0
332.823
342.808
349.465
356.121
184
P-9-13-0
332.823
342.808
349.465
356.121
185
P-9-14-0
332.823
342.808
349.465
356.121
186
P-9-15-0
212.149
218.513
222.756
226.999
187
P-9-16-0
332.823
342.808
349.465
356.121
188
P-9-17-0
331.392
341.334
347.962
354.589
189
Q-5-10-0
433.775
446.788
455.464
464.139
190
Q-5-11-0
325.103
334.856
341.358
347.860
191
Q-5-12-0
GIGI
286.537
295.133
300.864
306.594
192
Q-5-13-0
MEDICAL CHECK-UP
217.755
224.288
228.643
232.998
193
Q-5-14-0
239.602
246.790
251.582
256.374


DAN URETHRA
URETHRA
TRANSURETHRA
TRANSURETHRA
SALURAN KEMIH
KEMIH
KEMIH
PROSEDUR DIALISIS
CAESAR
VAGINAL/JALAN LAHIR

ASPIRASI
- 172 No
Kode
INA-CBG
194
Q-5-15-0
195
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
164.774
169.718
173.013
176.309
Q-5-16-0
VAKSINASI
186.233
191.820
195.545
199.269
196
Q-5-17-0
PASANG INFUS
161.087
165.919
169.141
172.363
197
Q-5-18-0
303.216
312.312
318.376
324.441
198
Q-5-19-0
338.977
349.146
355.926
362.705
199
Q-5-20-0
ABORSI MENGANCAM
227.205
234.021
238.565
243.109
200
Q-5-21-0
ABORSI
224.111
230.834
235.316
239.798
201
Q-5-22-0
239.602
246.790
251.582
256.374
202
Q-5-23-0
293.336
302.136
308.003
313.870
203
Q-5-24-0
200.344
206.355
210.362
214.369
204
Q-5-25-0
312.433
321.806
328.055
334.304
205
Q-5-26-0
BRONKIAL AKUT
442.228
455.494
464.339
473.184
206
Q-5-27-0
314.711
324.152
330.446
336.741
207
Q-5-28-0
255.380
263.041
268.149
273.256
208
Q-5-29-0

JANTUNG LAIN-LAIN
723.022
744.712
759.173
773.633
209
Q-5-30-0
837.904
863.041
879.799
896.557
210
Q-5-31-0
FRAKTUR
298.931
307.899
313.877
319.856
211
Q-5-32-0
SALURAN KEMIH AKUT
346.229
356.616
363.541
370.465
212
Q-5-33-0
HEMATOLOGI AKUT
362.501
373.376
380.626
387.876
213
Q-5-34-0
INFEKSI VIRUS HIV
514.957
530.406
540.705
551.004
214
Q-5-35-0
INFEKSI AKUT
583.948
601.466
613.145
624.824
215
Q-5-36-0
680.045
700.446
714.047
727.648
216
Q-5-37-0

SHOCK
346.858
357.263
364.201
371.138
217
Q-5-38-0
PARU AKUT
462.546
476.422
485.673
494.924
218
Q-5-39-0
295.995
304.875
310.795
316.715
219
Q-5-40-0
290.419
299.131
304.940
310.748
220
Q-5-41-0
402.044
414.105
422.146
430.187
221
Q-5-42-0
315.218
324.675
330.979
337.284
222
Q-5-43-0
453.933
467.550
476.629
485.708
223
Q-5-44-0
370.472
381.586
388.996
396.405
224
T-2-10-0

TERAPI DETOKSIKASI
192.158
197.922
201.765
205.609
225
U-2-10-0
2.564.559
2.641.496
2.692.787
2.744.078
226
U-2-11-0

LEHER
3.048.264
3.139.712
3.200.677
3.261.642
227
U-2-12-0
335.389
345.450
352.158
358.866
- 173 No
Kode
INA-CBG
228
U-2-13-0
229
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
439.703
452.894
461.688
470.482
U-2-14-0
816.768
841.271
857.607
873.942
230
U-2-15-0
464.070
477.992
487.273
496.555
231
U-2-21-0
232
U-2-22-0
233
U-2-23-0
234

(RHINOPLASTY)
540.569
556.786
567.598
578.409
1.044.423
1.075.755
1.096.644
1.117.532
1.368.531
1.409.587
1.436.958
1.464.328
U-2-24-0
1.153.374
1.187.976
1.211.043
1.234.111
235
U-2-25-0
439.703
452.894
461.688
470.482
236
U-2-31-0
353.344
363.945
371.012
378.078
237
U-2-32-0
439.703
452.894
461.688
470.482
238
U-3-10-0
420.379
432.990
441.398
449.806
239
U-3-11-0
446.311
459.701
468.627
477.553
240
U-3-12-0
197.358
203.279
207.226
211.173
241
U-3-13-0
433.809
446.823
455.500
464.176
242
U-3-14-0
398.581
410.538
418.510
426.482
243
U-3-15-0
347.598
358.026
364.978
371.930
244
U-3-16-0
PROSEDUR PADA GIGI
392.028
403.788
411.629
419.469
245
V-2-10-0

PROSTAT
3.824.682
3.939.423
4.015.917
4.092.410
246
V-2-11-0
431.327
444.267
452.893
461.520
1.376.425
1.417.718
1.445.247
1.472.775
607.813
626.048
638.204
650.360
607.813
626.048
638.204
650.360

RONGGA HIDUNG
TENGGOROKAN
PROSEDUR PADA PENIS

SKROTUM
SKROTUM
TRANSURETHRAL
247
V-2-12-0
248
V-2-13-0
249
V-2-14-0
250
V-2-15-0
SIRKUMSISI/SUNAT
332.823
342.808
349.465
356.121
251
V-3-10-0
694.125
714.949
728.832
742.714
252
V-3-11-0
1.468.436
1.512.489
1.541.857
1.571.226
253
V-3-12-0
847.766
873.199
890.155
907.110
254
W-2-10-0
310.429
319.742
325.950
332.159
255
W-2-11-0
793.340
817.140
833.007
848.874
256
W-2-12-0
1.468.436
1.512.489
1.541.857
1.571.226
257
W-2-13-0
235.511
242.576
247.286
251.997
258
W-2-21-0
3.675.101
3.785.354
3.858.856
3.932.358
259
W-2-22-0
386.476
398.071
405.800
413.530

PROSEDUR ABORSI
RAHIM & LEHER RAHIM
TERHALANG/TERGANGGU
TERHALANG/TERGANGGU
PANGGUL TERBUKA
PANGGUL TERBUKA
- 174 No
Kode
INA-CBG
260
W-2-23-0
Deskripsi (INA-CBG)
JALAN LAHIR
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.035.916
1.066.993
1.087.712
1.108.430
3.400.596
3.502.614
3.570.626
3.638.638
2.384.993
2.456.542
2.504.242
2.551.942
1.013.653
1.044.063
1.064.336
1.084.609
261
W-2-31-0
262
W-2-32-0
263
W-2-33-0
264
W-2-34-0
344.761
355.104
361.999
368.895
265
W-3-10-0
837.903
863.041
879.799
896.557
266
W-3-11-0
669.796
689.890
703.286
716.682
267
W-3-12-0
310.429
319.742
325.950
332.159
268
Z-3-10-0
3.514.467
3.619.901
3.690.190
3.760.479
269
Z-3-11-0

EMPEDU
2.686.173
2.766.758
2.820.481
2.874.205
270
Z-3-12-0
448.526
461.982
470.952
479.923
271
Z-3-13-0

LAIN-LAIN
2.737.028
2.819.138
2.873.879
2.928.619
272
Z-3-14-0
DIAGNOSTIK TIDUR
541.195
557.431
568.255
579.079
273
Z-3-15-0
353.344
363.945
371.012
378.078
274
Z-3-16-0

(MRI)
1.134.128
1.168.152
1.190.834
1.213.517
275
Z-3-17-0
PENGOBATAN NUKLIR
476.131
490.415
499.938
509.461
276
Z-3-18-0
CT-SCAN KEPALA
458.743
472.506
481.681
490.856
277
Z-3-19-0
CT SCAN LAIN-LAIN
477.463
491.787
501.336
510.885
278
Z-3-20-0
324.734
334.476
340.971
347.465
279
Z-3-21-0
310.429
319.742
325.950
332.159
280
Z-3-22-0
349.980
360.480
367.479
374.479
281
Z-3-23-0
364.535
375.471
382.762
390.052
282
Z-3-24-0
716.239
737.726
752.051
766.376
283
Z-3-25-0
319.012
328.582
334.962
341.343
284
Z-3-26-0
360.546
371.363
378.574
385.785
285
Z-3-27-0
PERAWATAN LUKA
344.224
354.551
361.435
368.320
286
Z-3-28-0
IMAGING PAYUDARA
353.344
363.945
371.012
378.078
287
Z-3-29-0
IMAGING LAIN-LAIN
1.018.402
1.048.954
1.069.322
1.089.690
288
Z-3-30-0
FOTOTERAPI
171.869
177.025
180.462
183.899
- 175 5. RUMAH SAKIT PARU KELAS A

a. RawatInap
No
Kode
INA-CBG
A-4-10-i
SEPTIKEMIA RINGAN
2.736.833
2.818.938
2.873.675
2.928.411
A-4-10-ii
SEPTIKEMIA SEDANG
3.132.938
3.226.926
3.289.585
3.352.244
A-4-10-iii
SEPTIKEMIA BERAT
4.911.856
5.059.212
5.157.449
5.255.686
A-4-11-i
4.918.728
5.066.290
5.164.664
5.263.039
A-4-11-ii
7.598.866
7.826.832
7.978.809
8.130.787
A-4-11-iii
12.430.084
12.802.987
13.051.589
13.300.190
A-4-12-i
DEMAM RINGAN
1.929.531
1.987.417
2.026.008
2.064.598
A-4-12-ii
DEMAM SEDANG
2.767.495
2.850.520
2.905.870
2.961.219
A-4-12-iii
DEMAM BERAT
3.167.195
3.262.211
3.325.555
3.388.898
10
A-4-13-i
2.411.914
2.484.271
2.532.510
2.580.748
11
A-4-13-ii
2.894.297
2.981.126
3.039.012
3.096.897
12
A-4-13-iii
3.517.676
3.623.206
3.693.559
3.763.913
13
A-4-14-i
1.929.531
1.987.417
2.026.008
2.064.598
14
A-4-14-ii
3.064.499
3.156.434
3.217.723
3.279.013
15
A-4-14-iii
3.489.611
3.594.300
3.664.092
3.733.884
16
A-4-15-i
INFEKSI HIV RINGAN
2.894.297
2.981.126
3.039.012
3.096.897
17
A-4-15-ii
INFEKSI HIV SEDANG
4.341.445
4.471.688
4.558.517
4.645.346
18
A-4-15-iii
INFEKSI HIV BERAT
6.037.927
6.219.065
6.339.824
6.460.582
19
B-1-01-i
32.087.791
33.050.425
33.692.181
34.333.937
20
B-1-01-ii
35.401.413
36.463.455
37.171.483
37.879.512
21
B-1-01-iii
62.101.363
63.964.404
65.206.431
66.448.458
22
B-1-10-i
4.160.073
4.284.875
4.368.077
4.451.278
23
B-1-10-ii
10.601.870
10.919.927
11.131.964
11.344.001
24
B-1-10-iii
18.453.662
19.007.272
19.376.345
19.745.418
2.843.954
2.929.272
2.986.151
3.043.030
7.138.592
7.352.750
7.495.521
7.638.293
8.950.023
9.218.523
9.397.524
9.576.524
6.066.256
6.248.243
6.369.568
6.490.893
13.001.469
13.391.514
13.651.543
13.911.572
15.823.278
16.297.977
16.614.442
16.930.908
25
B-1-11-i
26
B-1-11-ii
27
B-1-11-iii
28
B-1-12-i
29
B-1-12-ii
30
B-1-12-iii
Deskripsi (INA-CBG)

LAIN-LAIN RINGAN
LAIN-LAIN SEDANG
LAIN-LAIN BERAT

(RINGAN)
(SEDANG)
(BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT
Regional 1
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
- 176 No
Kode
INA-CBG
31
B-1-13-i
32
B-1-13-ii
33
B-1-13-iii
34
B-1-14-i
35
B-1-14-ii
36
B-1-14-iii
37
B-4-10-i
38
Deskripsi (INA-CBG)
LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT
Regional 1
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
3.975.082
4.094.335
4.173.836
4.253.338
6.474.832
6.669.077
6.798.574
6.928.070
9.545.719
9.832.091
10.023.005
10.213.920
5.397.882
5.559.818
5.667.776
5.775.734
6.003.534
6.183.640
6.303.711
6.423.781
9.391.815
9.673.570
9.861.406
10.049.242
1.509.610
1.554.898
1.585.090
1.615.282
B-4-10-ii
2.411.914
2.484.271
2.532.510
2.580.748
39
B-4-10-iii
3.687.530
3.798.156
3.871.907
3.945.657
40
B-4-11-i
3.646.298
3.755.687
3.828.613
3.901.539
41
B-4-11-ii
5.543.284
5.709.582
5.820.448
5.931.313
42
B-4-11-iii
5.970.309
6.149.418
6.268.824
6.388.231
43
B-4-12-i
3.199.377
3.295.358
3.359.346
3.423.333
44
B-4-12-ii
4.535.929
4.672.007
4.762.725
4.853.444
45
B-4-12-iii
8.815.985
9.080.465
9.256.785
9.433.104
46
B-4-13-i
2.894.297
2.981.126
3.039.012
3.096.897
47
B-4-13-ii
4.516.709
4.652.210
4.742.544
4.832.878
48
B-4-13-iii
6.855.406
7.061.068
7.198.176
7.335.284
49
B-4-14-i
2.894.297
2.981.126
3.039.012
3.096.897
50
B-4-14-ii
3.376.680
3.477.980
3.545.513
3.613.047
51
B-4-14-iii
4.504.830
4.639.975
4.730.072
4.820.168
52
C-4-10-i
2.818.461
2.903.015
2.959.384
3.015.753
53
C-4-10-ii
5.475.974
5.640.253
5.749.772
5.859.292
54
C-4-10-iii
LEUKEMIA AKUT BERAT
9.165.273
9.440.231
9.623.537
9.806.842
55
C-4-11-i
2.894.297
2.981.126
3.039.012
3.096.897
56
C-4-11-ii
3.859.062
3.974.834
4.052.015
4.129.197
57
C-4-11-iii
6.560.858
6.757.683
6.888.901
7.020.118
58
C-4-12-i
RADIOTERAPI RINGAN
1.929.531
1.987.417
2.026.008
2.064.598
59
C-4-12-ii
RADIOTERAPI SEDANG
5.312.582
5.471.959
5.578.211
5.684.463
60
C-4-12-iii
RADIOTERAPI BERAT
10.785.606
11.109.174
11.324.886
11.540.598
61
C-4-13-i
KEMOTERAPI RINGAN
1.929.531
1.987.417
2.026.008
2.064.598
62
C-4-13-ii
KEMOTERAPI SEDANG
3.859.062
3.974.834
4.052.015
4.129.197
63
C-4-13-iii
KEMOTERAPI BERAT
5.049.298
5.200.776
5.301.762
5.402.748

PANCREAS RINGAN
PANCREAS SEDANG
PANCREAS BERAT
(RINGAN)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT
- 177 No
Kode
INA-CBG
64
C-4-14-i
65
C-4-14-ii
66
C-4-14-iii
67
D-1-10-i
68
D-1-10-ii
69
D-1-10-iii
70
D-1-11-i
71
Deskripsi (INA-CBG)
RINGAN
SEDANG
BERAT
TULANG RINGAN
TULANG SEDANG
TULANG BERAT
Regional 1
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
2.502.086
2.577.148
2.627.190
2.677.232
3.656.208
3.765.894
3.839.018
3.912.142
5.573.783
5.740.996
5.852.472
5.963.947
20.532.500
21.148.475
21.559.125
21.969.775
31.272.572
32.210.749
32.836.201
33.461.652
42.382.880
43.654.367
44.502.024
45.349.682
4.220.279
4.346.887
4.431.293
4.515.698
D-1-11-ii
11.007.262
11.337.480
11.557.625
11.777.770
72
D-1-11-iii
15.595.481
16.063.345
16.375.255
16.687.165
73
D-1-20-i
5.198.494
5.354.448
5.458.418
5.562.388
74
D-1-20-ii
11.696.611
12.047.509
12.281.441
12.515.373
75
D-1-20-iii
21.143.560
21.777.867
22.200.738
22.623.609
76
D-4-10-i
1.853.433
1.909.036
1.946.105
1.983.174
77
D-4-10-ii
3.742.430
3.854.703
3.929.552
4.004.400
78
D-4-10-iii
4.823.828
4.968.543
5.065.019
5.161.496
79
D-4-11-i
4.220.849
4.347.475
4.431.892
4.516.309
80
D-4-11-ii
7.543.794
7.770.107
7.920.983
8.071.859
81
D-4-11-iii
10.327.905
10.637.742
10.844.300
11.050.859
82
D-4-12-i
2.474.164
2.548.388
2.597.872
2.647.355
83
D-4-12-ii
3.431.908
3.534.865
3.603.503
3.672.142
84
D-4-12-iii
5.269.697
5.427.787
5.533.181
5.638.575
85
D-4-13-i
1.929.531
1.987.417
2.026.008
2.064.598
86
D-4-13-ii
2.894.297
2.981.126
3.039.012
3.096.897
87
D-4-13-iii
3.376.680
3.477.980
3.545.513
3.613.047
88
D-4-14-i
2.324.850
2.394.595
2.441.092
2.487.589
89
D-4-14-ii
5.427.955
5.590.794
5.699.353
5.807.912
90
D-4-14-iii
6.474.800
6.669.044
6.798.540
6.928.036
91
E-1-01-i
4.625.290
4.764.049
4.856.555
4.949.060
92
E-1-01-ii
6.058.690
6.240.451
6.361.625
6.482.798
93
E-1-01-iii
13.732.161
14.144.126
14.418.769
14.693.413
94
E-1-10-i
4.712.923
4.854.311
4.948.569
5.042.828
95
E-1-10-ii
5.720.382
5.891.994
6.006.401
6.120.809
96
E-1-10-iii
12.056.882
12.418.588
12.659.726
12.900.864


RINGAN
SEDANG
BERAT
- 178 No
Kode
INA-CBG
97
E-1-20-i
98
E-1-20-ii
99
E-1-20-iii
100
E-4-10-i
101
E-4-10-ii
102
E-4-10-iii
103
E-4-11-i
104
E-4-11-ii
105
E-4-11-iii
106
E-4-12-i
107
E-4-12-ii
108
E-4-12-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
BERAT
Regional 1
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
5.457.662
5.621.392
5.730.546
5.839.699
7.309.657
7.528.947
7.675.140
7.821.333
16.196.134
16.682.018
17.005.941
17.329.864
2.411.914
2.484.271
2.532.510
2.580.748
3.430.249
3.533.157
3.601.762
3.670.367
6.556.854
6.753.560
6.884.697
7.015.834
2.057.867
2.119.603
2.160.760
2.201.918
3.893.131
4.009.925
4.087.788
4.165.650
6.419.952
6.612.551
6.740.950
6.869.349
2.458.864
2.532.629
2.581.807
2.630.984
4.271.509
4.399.655
4.485.085
4.570.515
6.975.048
7.184.299
7.323.800
7.463.301
2.593.620
2.671.428
2.723.301
2.775.173
4.453.263
4.586.861
4.675.926
4.764.992
7.705.270
7.936.428
8.090.534
8.244.639

RINGAN
SEDANG
BERAT
109
E-4-13-i
110
E-4-13-ii
111
E-4-13-iii
112
F-4-10-i
SCHIZOFRENIA RINGAN
3.171.191
3.266.326
3.329.750
3.393.174
113
F-4-10-ii
SCHIZOFRENIA SEDANG
3.521.709
3.627.361
3.697.795
3.768.229
114
F-4-10-iii
SCHIZOFRENIA BERAT
5.213.968
5.370.387
5.474.667
5.578.946
115
F-4-11-i
2.923.070
3.010.762
3.069.223
3.127.685
116
F-4-11-ii
3.405.654
3.507.823
3.575.936
3.644.050
117
F-4-11-iii
DEPRESI MAYOR BERAT
4.367.293
4.498.312
4.585.657
4.673.003
1.447.148
1.490.563
1.519.506
1.548.449
2.066.323
2.128.312
2.169.639
2.210.965
4.482.540
4.617.016
4.706.667
4.796.318

IMPULSE RINGAN
IMPULSE SEDANG
IMPULSE BERAT
118
F-4-12-i
119
F-4-12-ii
120
F-4-12-iii
121
F-4-13-i
2.362.284
2.433.153
2.480.399
2.527.644
122
F-4-13-ii
3.128.272
3.222.120
3.284.685
3.347.251
123
F-4-13-iii
4.033.507
4.154.512
4.235.182
4.315.852
124
F-4-14-i
DEPRESI RINGAN
1.653.599
1.703.207
1.736.279
1.769.351
125
F-4-14-ii
DEPRESI SEDANG
2.121.076
2.184.709
2.227.130
2.269.552
126
F-4-14-iii
DEPRESI BERAT
2.854.003
2.939.623
2.996.703
3.053.783
127
F-4-15-i
1.966.035
2.025.016
2.064.337
2.103.658
128
F-4-15-ii
2.894.297
2.981.126
3.039.012
3.096.897
129
F-4-15-iii
3.811.966
3.926.325
4.002.565
4.078.804
- 179 No
Kode
INA-CBG
130
F-4-16-i
131
F-4-16-ii
132
F-4-16-iii
133
F-4-17-i
134
F-4-17-ii
135
F-4-17-iii
136
F-4-18-i
137
Deskripsi (INA-CBG)
RINGAN
SEDANG
BERAT
Regional 1
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
4.234.455
4.361.489
4.446.178
4.530.867
4.922.448
5.070.122
5.168.571
5.267.020
6.570.647
6.767.766
6.899.179
7.030.592
977.686
1.007.016
1.026.570
1.046.124
2.865.503
2.951.468
3.008.779
3.066.089
3.057.281
3.149.000
3.210.145
3.271.291
3.670.283
3.780.392
3.853.797
3.927.203
F-4-18-ii
4.038.348
4.159.499
4.240.265
4.321.032
138
F-4-18-iii
6.225.466
6.412.230
6.536.739
6.661.248
139
F-4-19-i
2.814.761
2.899.204
2.955.499
3.011.794
140
F-4-19-ii
3.604.374
3.712.505
3.784.592
3.856.680
141
F-4-19-iii
4.487.493
4.622.118
4.711.868
4.801.618
142
G-1-01-i
8.948.725
9.217.187
9.396.162
9.575.136
143
G-1-01-ii
15.146.796
15.601.200
15.904.136
16.207.072
144
G-1-01-iii
29.322.505
30.202.181
30.788.631
31.375.081
145
G-1-10-i
4.465.865
4.599.841
4.689.159
4.778.476
146
G-1-10-ii
6.304.692
6.493.832
6.619.926
6.746.020
147
G-1-10-iii
7.472.406
7.696.578
7.846.027
7.995.475
148
G-1-11-i
5.151.509
5.306.054
5.409.084
5.512.115
149
G-1-11-ii
10.579.012
10.896.382
11.107.962
11.319.543
150
G-1-11-iii
22.151.489
22.816.034
23.259.063
23.702.093
151
G-1-12-i
4.006.356
4.126.547
4.206.674
4.286.801
152
G-1-12-ii
9.172.154
9.447.318
9.630.761
9.814.204
153
G-1-12-iii
16.177.668
16.662.998
16.986.551
17.310.104
154
G-1-13-i
1.056.601
1.088.299
1.109.431
1.130.563
155
G-1-13-ii
2.837.914
2.923.052
2.979.810
3.036.568
156
G-1-13-iii
6.403.530
6.595.636
6.723.706
6.851.777
157
G-1-20-i
5.048.350
5.199.800
5.300.767
5.401.734
158
G-1-20-ii
6.820.486
7.025.100
7.161.510
7.297.920
159
G-1-20-iii
16.699.157
17.200.132
17.534.115
17.868.098
160
G-1-30-i
6.438.715
6.631.877
6.760.651
6.889.426
161
G-1-30-ii
16.805.665
17.309.835
17.645.948
17.982.061
162
G-1-30-iii
21.634.084
22.283.106
22.715.788
23.148.470

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

RINGAN
SEDANG
BERAT
- 180 No
Kode
INA-CBG
163
G-4-10-i
164
G-4-10-ii
165
G-4-10-iii
166
G-4-11-i
167
G-4-11-ii
168
G-4-11-iii
169
G-4-12-i
170
G-4-12-ii
171
G-4-12-iii
172
G-4-13-i
173
G-4-13-ii
174
G-4-13-iii
175
G-4-14-i
176
G-4-14-ii
177
G-4-14-iii
178
G-4-15-i
179
G-4-15-ii
180
G-4-15-iii
181
G-4-16-i
182
Deskripsi (INA-CBG)
BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
DEGENERATIF RINGAN
DEGENERATIF SEDANG
DEGENERATIF BERAT
RINGAN
SEDANG
BERAT
TRAUMATIK RINGAN
TRAUMATIK SEDANG
TRAUMATIK BERAT
DENGAN INFARK BERAT
TANPA INFARK RINGAN
TANPA INFARK SEDANG
TANPA INFARK BERAT
Regional 1
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
2.894.297
2.981.126
3.039.012
3.096.897
3.376.680
3.477.980
3.545.513
3.613.047
5.158.630
5.313.389
5.416.561
5.519.734
4.775.382
4.918.644
5.014.151
5.109.659
5.539.443
5.705.627
5.816.415
5.927.204
8.118.150
8.361.694
8.524.057
8.686.420
3.571.566
3.678.713
3.750.144
3.821.575
4.500.173
4.635.178
4.725.181
4.815.185
6.535.965
6.732.044
6.862.763
6.993.483
1.987.195
2.046.811
2.086.555
2.126.299
3.376.680
3.477.980
3.545.513
3.613.047
3.991.715
4.111.466
4.191.300
4.271.135
3.634.284
3.743.312
3.815.998
3.888.684
5.979.623
6.159.012
6.278.604
6.398.197
7.486.624
7.711.223
7.860.956
8.010.688
3.719.795
3.831.389
3.905.785
3.980.181
4.494.815
4.629.659
4.719.555
4.809.452
5.554.365
5.720.996
5.832.083
5.943.170
2.411.914
2.484.271
2.532.510
2.580.748
G-4-16-ii
3.607.039
3.715.250
3.787.391
3.859.532
183
G-4-16-iii
6.546.132
6.742.516
6.873.438
7.004.361
184
G-4-17-i
3.446.846
3.550.251
3.619.188
3.688.125
185
G-4-17-ii
4.277.687
4.406.018
4.491.571
4.577.125
186
G-4-17-iii
7.169.439
7.384.522
7.527.911
7.671.299
187
G-4-18-i
2.894.297
2.981.126
3.039.012
3.096.897
188
G-4-18-ii
4.149.921
4.274.418
4.357.417
4.440.415
189
G-4-18-iii
4.396.418
4.528.311
4.616.239
4.704.167
190
G-4-19-i
2.411.914
2.484.271
2.532.510
2.580.748
191
G-4-19-ii
4.888.068
5.034.710
5.132.471
5.230.233
192
G-4-19-iii
7.291.446
7.510.189
7.656.018
7.801.847

PERIFER RINGAN
PERIFER SEDANG
PERIFER BERAT
PERSARAFAN RINGAN
PERSARAFAN SEDANG
PERSARAFAN BERAT
SEDANG
- 181 No
Kode
INA-CBG
193
G-4-20-i
1.688.340
1.738.990
1.772.757
1.806.524
194
G-4-20-ii
2.397.444
2.469.368
2.517.317
2.565.265
195
G-4-20-iii
4.088.204
4.210.850
4.292.614
4.374.378
196
G-4-21-i
1.956.400
2.015.092
2.054.220
2.093.348
197
G-4-21-ii
4.051.899
4.173.456
4.254.494
4.335.532
198
G-4-21-iii
4.773.615
4.916.824
5.012.296
5.107.768
199
G-4-22-i
1.929.531
1.987.417
2.026.008
2.064.598
200
G-4-22-ii
2.411.914
2.484.271
2.532.510
2.580.748
201
G-4-22-iii
2.767.096
2.850.109
2.905.451
2.960.793
202
G-4-23-i
1.929.531
1.987.417
2.026.008
2.064.598
203
G-4-23-ii
2.411.914
2.484.271
2.532.510
2.580.748
204
G-4-23-iii
3.447.660
3.551.090
3.620.043
3.688.996
205
G-4-24-i
1.929.531
1.987.417
2.026.008
2.064.598
206
G-4-24-ii
2.411.914
2.484.271
2.532.510
2.580.748
207
G-4-24-iii
TRAUMA KEPALA BERAT
5.068.376
5.220.427
5.321.795
5.423.162
208
G-4-25-i
GEGAR OTAK RINGAN
1.833.431
1.888.434
1.925.103
1.961.772
209
G-4-25-ii
GEGAR OTAK SEDANG
2.308.330
2.377.580
2.423.747
2.469.913
210
G-4-25-iii
GEGAR OTAK BERAT
3.011.733
3.102.085
3.162.319
3.222.554
211
G-4-26-i
2.894.297
2.981.126
3.039.012
3.096.897
212
G-4-26-ii
3.376.680
3.477.980
3.545.513
3.613.047
213
G-4-26-iii
6.445.609
6.638.977
6.767.889
6.896.801
214
H-1-20-i
2.773.492
2.856.697
2.912.167
2.967.636
215
H-1-20-ii
5.057.777
5.209.510
5.310.665
5.411.821
216
H-1-20-iii
6.878.260
7.084.608
7.222.173
7.359.738
217
H-1-30-i
2.715.513
2.796.978
2.851.288
2.905.599
218
H-1-30-ii
3.095.685
3.188.555
3.250.469
3.312.382
219
H-1-30-iii
5.165.038
5.319.989
5.423.290
5.526.590
220
H-4-10-i
2.894.297
2.981.126
3.039.012
3.096.897
221
H-4-10-ii
4.823.828
4.968.543
5.065.019
5.161.496
222
H-4-10-iii
7.864.264
8.100.192
8.257.477
8.414.763
223
H-4-11-i
1.970.698
2.029.819
2.069.233
2.108.647
224
H-4-11-ii
2.201.962
2.268.020
2.312.060
2.356.099
225
H-4-11-iii
3.148.599
3.243.057
3.306.029
3.369.001
226
H-4-12-i
2.734.265
2.816.293
2.870.978
2.925.663
Deskripsi (INA-CBG)

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)

RINGAN
SEDANG
Regional 1
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
- 182 No
Kode
INA-CBG
227
H-4-12-ii
3.703.741
3.814.853
3.888.928
3.963.002
228
H-4-12-iii
6.179.438
6.364.822
6.488.410
6.611.999
229
I-1-01-i
41.627.323
42.876.143
43.708.689
44.541.235
230
I-1-01-ii
42.543.341
43.819.641
44.670.508
45.521.375
231
I-1-01-iii
67.153.848
69.168.463
70.511.540
71.854.617
232
I-1-02-i
23.094.599
23.787.437
24.249.329
24.711.221
233
I-1-02-ii
29.792.033
30.685.794
31.281.634
31.877.475
234
I-1-02-iii
36.720.412
37.822.025
38.556.433
39.290.841
235
I-1-03-i
14.222.476
14.649.150
14.933.599
15.218.049
236
I-1-03-ii
19.494.351
20.079.182
20.469.069
20.858.956
237
I-1-03-iii
28.591.715
29.449.467
30.021.301
30.593.135
238
I-1-04-i
17.351.004
17.871.534
18.218.554
18.565.574
239
I-1-04-ii
22.287.672
22.956.302
23.402.056
23.847.809
240
I-1-04-iii
47.512.689
48.938.070
49.888.324
50.838.578
241
I-1-05-i
30.566.381
31.483.372
32.094.700
32.706.028
242
I-1-05-ii
36.679.657
37.780.047
38.513.640
39.247.233
243
I-1-05-iii
50.470.977
51.985.106
52.994.526
54.003.945
244
I-1-06-i
14.408.314
14.840.563
15.128.730
15.416.896
245
I-1-06-ii
21.745.566
22.397.933
22.832.844
23.267.756
246
I-1-06-iii
27.994.318
28.834.147
29.394.034
29.953.920
18.948.024
19.516.465
19.895.425
20.274.386
23.376.237
24.077.524
24.545.049
25.012.573
25.503.322
26.268.422
26.778.488
27.288.555
3.604.376
3.712.507
3.784.595
3.856.683
4.007.706
4.127.937
4.208.091
4.288.245
5.333.035
5.493.026
5.599.687
5.706.347
11.046.799
11.378.203
11.599.139
11.820.075
15.327.949
15.787.788
16.094.347
16.400.906
21.378.871
22.020.237
22.447.815
22.875.392
247
I-1-07-i
248
I-1-07-ii
249
I-1-07-iii
250
I-1-11-i
251
I-1-11-ii
252
I-1-11-iii
253
I-1-12-i
254
I-1-12-ii
255
I-1-12-iii
Deskripsi (INA-CBG)

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
KATETERISASI RINGAN
KATETERISASI SEDANG
KATETERISASI BERAT
RINGAN
SEDANG
BERAT

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
Regional 1
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
- 183 No
Kode
INA-CBG
256
I-1-13-i
257
I-1-13-ii
258
I-1-13-iii
259
I-1-14-i
260
I-1-14-ii
261
I-1-14-iii
262
I-1-15-i
263
Deskripsi (INA-CBG)
KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT
Regional 1
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
6.498.117
6.693.061
6.823.023
6.952.985
7.560.161
7.786.966
7.938.169
8.089.372
13.781.668
14.195.118
14.470.751
14.746.385
23.773.852
24.487.067
24.962.544
25.438.021
29.547.502
30.433.927
31.024.877
31.615.827
38.717.416
39.878.938
40.653.287
41.427.635
4.658.535
4.798.291
4.891.462
4.984.632
I-1-15-ii
13.646.046
14.055.427
14.328.348
14.601.269
264
I-1-15-iii
70.633.971
72.752.990
74.165.669
75.578.349
265
I-1-16-i
10.188.794
10.494.457
10.698.233
10.902.009
266
I-1-16-ii
26.490.863
27.285.589
27.815.407
28.345.224
267
I-1-16-iii
30.556.561
31.473.258
32.084.389
32.695.520
268
I-1-17-i
3.267.628
3.365.657
3.431.009
3.496.362
269
I-1-17-ii
6.768.442
6.971.496
7.106.864
7.242.233
270
I-1-17-iii
39.239.311
40.416.491
41.201.277
41.986.063
271
I-1-20-i
3.898.870
4.015.836
4.093.814
4.171.791
272
I-1-20-ii
7.017.966
7.228.505
7.368.864
7.509.224
273
I-1-20-iii
9.357.289
9.638.007
9.825.153
10.012.299
274
I-1-30-i
11.559.239
11.906.017
12.137.201
12.368.386
275
I-1-30-ii
24.045.553
24.766.920
25.247.831
25.728.742
276
I-1-30-iii
37.261.874
38.379.730
39.124.968
39.870.205
277
I-1-40-i
15.544.571
16.010.908
16.321.800
16.632.691
278
I-1-40-ii
21.588.070
22.235.712
22.667.474
23.099.235
279
I-1-40-iii
27.050.842
27.862.367
28.403.384
28.944.401
280
I-4-10-i
4.520.813
4.656.437
4.746.854
4.837.270
281
I-4-10-ii
7.138.445
7.352.598
7.495.367
7.638.136
282
I-4-10-iii
10.297.829
10.606.764
10.812.721
11.018.677
283
I-4-11-i
5.360.502
5.521.317
5.628.527
5.735.737
284
I-4-11-ii
6.633.642
6.832.651
6.965.324
7.097.997

DARAH VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
- 184 No
Kode
INA-CBG
285
I-4-11-iii
286
I-4-12-i
287
Deskripsi (INA-CBG)
Regional 1
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
11.739.972
12.092.171
12.326.970
12.561.770
4.695.243
4.836.100
4.930.005
5.023.909
I-4-12-ii
6.700.098
6.901.101
7.035.103
7.169.105
288
I-4-12-iii
8.128.161
8.372.006
8.534.569
8.697.132
289
I-4-13-i
4.217.618
4.344.147
4.428.499
4.512.852
290
I-4-13-ii
6.127.339
6.311.159
6.433.706
6.556.253
291
I-4-13-iii
12.541.952
12.918.211
13.169.050
13.419.889
292
I-4-14-i
2.622.969
2.701.658
2.754.118
2.806.577
293
I-4-14-ii
3.069.262
3.161.340
3.222.725
3.284.110
294
I-4-14-iii
4.756.335
4.899.025
4.994.151
5.089.278
295
I-4-15-i
3.859.062
3.974.834
4.052.015
4.129.197
296
I-4-15-ii
5.524.439
5.690.172
5.800.661
5.911.149
297
I-4-15-iii
6.296.531
6.485.427
6.611.358
6.737.288
298
I-4-16-i
2.894.297
2.981.126
3.039.012
3.096.897
299
I-4-16-ii
4.690.658
4.831.378
4.925.191
5.019.004
300
I-4-16-iii
5.909.396
6.086.678
6.204.866
6.323.054
301
I-4-17-i
HIPERTENSI RINGAN
2.590.336
2.668.046
2.719.852
2.771.659
302
I-4-17-ii
HIPERTENSI SEDANG
3.668.173
3.778.218
3.851.582
3.924.945
303
I-4-17-iii
HIPERTENSI BERAT
4.462.508
4.596.383
4.685.633
4.774.883
3.814.820
3.929.265
4.005.561
4.081.858
5.844.049
6.019.371
6.136.252
6.253.133
7.878.715
8.115.077
8.272.651
8.430.225
2.985.597
3.075.165
3.134.877
3.194.589
4.890.314
5.037.024
5.134.830
5.232.636
5.829.210
6.004.086
6.120.671
6.237.255

VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT


RINGAN
SEDANG
KONGENITAL BERAT
RINGAN
SEDANG
BERAT
304
I-4-18-i
305
I-4-18-ii
306
I-4-18-iii
307
I-4-19-i
308
I-4-19-ii
309
I-4-19-iii
310
I-4-20-i
3.623.445
3.732.148
3.804.617
3.877.086
311
I-4-20-ii
4.174.479
4.299.713
4.383.203
4.466.693
312
I-4-20-iii
5.540.228
5.706.435
5.817.240
5.928.044
313
I-4-21-i
4.818.595
4.963.153
5.059.525
5.155.897
314
I-4-21-ii
6.010.885
6.191.211
6.311.429
6.431.647
315
I-4-21-iii
8.200.121
8.446.125
8.610.127
8.774.130
316
I-4-22-i
3.135.488
3.229.553
3.292.263
3.354.972
317
I-4-22-ii
3.613.021
3.721.411
3.793.672
3.865.932
- 185 No
Kode
INA-CBG
318
I-4-22-iii
319
I-4-23-i
320
I-4-23-ii
321
I-4-23-iii
322
I-4-24-i
323
I-4-24-ii
324
I-4-24-iii
325
J-1-01-i
326
J-1-01-ii
327
J-1-01-iii
328
J-1-02-i
329
J-1-02-ii
330
J-1-02-iii
331
J-1-10-i
332
J-1-10-ii
333
J-1-10-iii
334
J-1-20-i
335
J-1-20-ii
336
J-1-20-iii
337
J-1-30-i
338
J-1-30-ii
339
J-1-30-iii
340
J-4-10-i
341
Deskripsi (INA-CBG)
Regional 1
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
5.271.299
5.429.438
5.534.864
5.640.290
2.375.309
2.446.568
2.494.075
2.541.581
2.916.332
3.003.822
3.062.149
3.120.475
5.698.247
5.869.195
5.983.160
6.097.125
2.833.058
2.918.050
2.974.711
3.031.372
7.073.362
7.285.562
7.427.030
7.568.497
8.942.988
9.211.278
9.390.137
9.568.997
45.184.284
46.539.813
47.443.498
48.347.184
49.215.786
50.692.260
51.676.576
52.660.892
72.977.855
75.167.190
76.626.748
78.086.305
20.438.869
21.052.035
21.460.812
21.869.590
21.895.475
22.552.339
22.990.248
23.428.158
32.355.272
33.325.931
33.973.036
34.620.141
7.975.542
8.214.808
8.374.319
8.533.830
19.263.833
19.841.748
20.227.024
20.612.301
34.108.983
35.132.253
35.814.432
36.496.612
6.893.421
7.100.223
7.238.092
7.375.960
10.025.936
10.326.714
10.527.232
10.727.751
15.075.911
15.528.188
15.829.706
16.131.224
4.648.614
4.788.072
4.881.045
4.974.017
25.238.865
25.996.031
26.500.808
27.005.585
76.119.308
78.402.887
79.925.274
81.447.660
5.947.866
6.126.302
6.245.260
6.364.217
J-4-10-ii
8.504.735
8.759.877
8.929.971
9.100.066
342
J-4-10-iii
12.866.394
13.252.385
13.509.713
13.767.041
343
J-4-11-i
3.384.709
3.486.250
3.553.944
3.621.639
344
J-4-11-ii
4.711.438
4.852.781
4.947.009
5.041.238
345
J-4-11-iii
6.751.610
6.954.159
7.089.191
7.224.223
346
J-4-12-i
EMBOLI PARU RINGAN
5.738.313
5.910.462
6.025.229
6.139.995
347
J-4-12-ii
EMBOLI PARU SEDANG
7.430.919
7.653.847
7.802.465
7.951.084
348
J-4-12-iii
EMBOLI PARU BERAT
9.923.242
10.220.939
10.419.404
10.617.869

RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
- 186 No
Kode
INA-CBG
349
J-4-13-i
7.973.158
8.212.353
8.371.816
8.531.279
350
J-4-13-ii
11.720.542
12.072.158
12.306.569
12.540.980
351
J-4-13-iii
19.055.848
19.627.523
20.008.640
20.389.757
352
J-4-14-i
TUMOR PARU RINGAN
5.620.764
5.789.387
5.901.802
6.014.217
353
J-4-14-ii
TUMOR PARU SEDANG
9.101.781
9.374.835
9.556.870
9.738.906
354
J-4-14-iii
10.821.555
11.146.202
11.362.633
11.579.064
5.620.764
5.789.387
5.901.802
6.014.217
6.697.833
6.898.768
7.032.725
7.166.682
9.095.168
9.368.023
9.549.926
9.731.829
4.683.970
4.824.489
4.918.168
5.011.848
6.557.558
6.754.285
6.885.436
7.016.587
11.829.145
12.184.019
12.420.602
12.657.185
Deskripsi (INA-CBG)
TUMOR PARU BERAT

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
Regional 1
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
355
J-4-15-i
356
J-4-15-ii
357
J-4-15-iii
358
J-4-16-i
359
J-4-16-ii
360
J-4-16-iii
361
J-4-17-i
4.683.970
4.824.489
4.918.168
5.011.848
362
J-4-17-ii
5.620.764
5.789.387
5.901.802
6.014.217
363
J-4-17-iii
10.333.451
10.643.455
10.850.124
11.056.793
364
J-4-18-i
3.747.176
3.859.591
3.934.535
4.009.478
365
J-4-18-ii
5.152.367
5.306.938
5.409.985
5.513.033
366
J-4-18-iii
5.425.127
5.587.881
5.696.383
5.804.886
367
J-4-19-i
6.557.558
6.754.285
6.885.436
7.016.587
368
J-4-19-ii
7.494.352
7.719.182
7.869.069
8.018.957
369
J-4-19-iii
11.740.781
12.093.004
12.327.820
12.562.635
370
J-4-20-i
6.557.558
6.754.285
6.885.436
7.016.587
371
J-4-20-ii
7.494.352
7.719.182
7.869.069
8.018.957
372
J-4-20-iii
18.074.876
18.617.122
18.978.620
19.340.117
3.747.176
3.859.591
3.934.535
4.009.478
9.244.967
9.522.316
9.707.215
9.892.115
13.186.347
13.581.937
13.845.664
14.109.391
5.198.494
5.354.448
5.458.418
5.562.388
7.254.839
7.472.485
7.617.581
7.762.678
8.496.666
8.751.566
8.921.499
9.091.433

USUS BESAR (RINGAN)
USUS BESAR (SEDANG)
USUS BESAR (BERAT)
373
J-4-21-i
374
J-4-21-ii
375
J-4-21-iii
376
K-1-10-i
377
K-1-10-ii
378
K-1-10-iii
379
K-1-11-i
4.469.905
4.604.002
4.693.400
4.782.798
380
K-1-11-ii
5.868.446
6.044.499
6.161.868
6.279.237
381
K-1-11-iii
14.892.960
15.339.749
15.637.608
15.935.468
- 187 No
Kode
INA-CBG
382
K-1-12-i
383
K-1-12-ii
384
K-1-12-iii
385
K-1-13-i
386
Deskripsi (INA-CBG)
Regional 1
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
2.404.467
2.476.601
2.524.690
2.572.779
3.133.764
3.227.777
3.290.452
3.353.127
6.233.715
6.420.727
6.545.401
6.670.076
2.731.145
2.813.079
2.867.702
2.922.325
K-1-13-ii
4.770.525
4.913.641
5.009.052
5.104.462
387
K-1-13-iii
5.101.905
5.254.962
5.357.000
5.459.038
388
K-1-14-i
4.413.691
4.546.102
4.634.376
4.722.650
389
K-1-14-ii
5.184.381
5.339.912
5.443.600
5.547.287
390
K-1-14-iii
12.765.448
13.148.412
13.403.721
13.659.030
391
K-1-20-i
8.563.856
8.820.772
8.992.049
9.163.326
392
K-1-20-ii
11.952.885
12.311.471
12.550.529
12.789.587
393
K-1-20-iii
25.531.926
26.297.884
26.808.523
27.319.161
394
K-1-30-i
5.637.156
5.806.271
5.919.014
6.031.757
395
K-1-30-ii
10.396.987
10.708.897
10.916.837
11.124.776
396
K-1-30-iii
16.191.974
16.677.733
17.001.573
17.325.412
397
K-1-40-i
5.663.204
5.833.100
5.946.364
6.059.628
398
K-1-40-ii
6.231.794
6.418.747
6.543.383
6.668.019
399
K-1-40-iii
10.334.830
10.644.874
10.851.571
11.058.268
400
K-1-50-i
4.319.658
4.449.248
4.535.641
4.622.034
401
K-1-50-ii
5.594.161
5.761.986
5.873.869
5.985.753
402
K-1-50-iii
PROSEDUR ANAL BERAT
7.942.221
8.180.488
8.339.332
8.498.177
403
K-4-10-i
3.271.830
3.369.985
3.435.422
3.500.859
404
K-4-10-ii
3.914.937
4.032.385
4.110.684
4.188.983
405
K-4-10-iii
16.211.704
16.698.056
17.022.290
17.346.524
406
K-4-11-i
1.929.531
1.987.417
2.026.008
2.064.598
407
K-4-11-ii
2.894.297
2.981.126
3.039.012
3.096.897
408
K-4-11-iii
5.259.980
5.417.779
5.522.979
5.628.179
409
K-4-12-i
1.929.531
1.987.417
2.026.008
2.064.598
410
K-4-12-ii
2.882.690
2.969.170
3.026.824
3.084.478
411
K-4-12-iii
6.918.250
7.125.797
7.264.162
7.402.527
412
K-4-13-i
2.894.297
2.981.126
3.039.012
3.096.897
413
K-4-13-ii
3.748.827
3.861.292
3.936.268
4.011.245

RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)

(RINGAN)
(SEDANG)
- 188 No
Kode
INA-CBG
414
K-4-13-iii
415
K-4-14-i
416
K-4-14-ii
417
K-4-14-iii
418
K-4-15-i
419
K-4-15-ii
420
K-4-15-iii
421
K-4-16-i
422
Deskripsi (INA-CBG)
RINGAN
SEDANG
BERAT
Regional 1
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
6.131.440
6.315.383
6.438.012
6.560.641
2.411.914
2.484.271
2.532.510
2.580.748
3.264.274
3.362.202
3.427.487
3.492.773
4.937.525
5.085.651
5.184.402
5.283.152
2.411.914
2.484.271
2.532.510
2.580.748
4.535.056
4.671.108
4.761.809
4.852.510
6.452.568
6.646.146
6.775.197
6.904.248
2.411.914
2.484.271
2.532.510
2.580.748
K-4-16-ii
2.894.297
2.981.126
3.039.012
3.096.897
423
K-4-16-iii
3.532.865
3.638.851
3.709.508
3.780.166
424
K-4-17-i
1.929.531
1.987.417
2.026.008
2.064.598
425
K-4-17-ii
2.815.222
2.899.679
2.955.983
3.012.288
426
K-4-17-iii
3.746.773
3.859.176
3.934.112
4.009.047
427
K-4-18-i
1.929.531
1.987.417
2.026.008
2.064.598
428
K-4-18-ii
2.995.433
3.085.296
3.145.204
3.205.113
429
K-4-18-iii
3.543.582
3.649.889
3.720.761
3.791.633
430
L-1-20-i
19.745.377
20.337.739
20.732.646
21.127.554
431
L-1-20-ii
20.540.636
21.156.855
21.567.667
21.978.480
432
L-1-20-iii
31.470.625
32.414.744
33.044.156
33.673.569
433
L-1-30-i
8.955.922
9.224.599
9.403.718
9.582.836
434
L-1-30-ii
12.972.682
13.361.862
13.621.316
13.880.769
435
L-1-30-iii
13.682.131
14.092.595
14.366.238
14.639.881
436
L-1-40-i
3.616.141
3.724.625
3.796.948
3.869.270
437
L-1-40-ii
8.138.847
8.383.013
8.545.790
8.708.567
438
L-1-40-iii
13.793.195
14.206.991
14.482.855
14.758.719
439
L-1-50-i
6.498.117
6.693.061
6.823.023
6.952.985
440
L-1-50-ii
11.696.611
12.047.509
12.281.441
12.515.373
441
L-1-50-iii
14.142.857
14.567.143
14.850.000
15.132.857
442
L-4-10-i
2.894.297
2.981.126
3.039.012
3.096.897
443
L-4-10-ii
3.376.680
3.477.980
3.545.513
3.613.047
444
L-4-10-iii
6.830.734
7.035.656
7.172.271
7.308.885
445
L-4-11-i
2.737.478
2.819.602
2.874.351
2.929.101

(RINGAN)
(SEDANG)
(BERAT)
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
- 189 No
Kode
INA-CBG
446
L-4-11-ii
447
L-4-11-iii
448
L-4-12-i
449
Deskripsi (INA-CBG)
Regional 1
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
3.750.296
3.862.805
3.937.811
4.012.817
10.170.335
10.475.445
10.678.852
10.882.258
2.894.297
2.981.126
3.039.012
3.096.897
L-4-12-ii
4.246.605
4.374.003
4.458.935
4.543.867
450
L-4-12-iii
7.121.054
7.334.685
7.477.106
7.619.528
451
L-4-13-i
1.816.663
1.871.163
1.907.496
1.943.829
452
L-4-13-ii
2.094.719
2.157.561
2.199.455
2.241.350
453
L-4-13-iii
3.142.242
3.236.509
3.299.354
3.362.199
454
L-4-14-i
1.929.531
1.987.417
2.026.008
2.064.598
455
L-4-14-ii
2.894.297
2.981.126
3.039.012
3.096.897
456
L-4-14-iii
4.525.285
4.661.044
4.751.549
4.842.055
457
M-1-01-i
9.407.216
9.689.433
9.877.577
10.065.721
458
M-1-01-ii
10.499.975
10.814.974
11.024.974
11.234.973
459
M-1-01-iii
14.749.620
15.192.109
15.487.101
15.782.094
460
M-1-02-i
6.662.708
6.862.590
6.995.844
7.129.098
461
M-1-02-ii
10.938.900
11.267.067
11.485.845
11.704.623
462
M-1-02-iii
19.809.847
20.404.142
20.800.339
21.196.536
16.895.104
17.401.957
17.739.860
18.077.762
19.772.213
20.365.379
20.760.824
21.156.268
20.144.163
20.748.488
21.151.371
21.554.254
4.395.189
4.527.045
4.614.948
4.702.852
5.634.587
5.803.624
5.916.316
6.029.008
7.050.623
7.262.142
7.403.154
7.544.167
6.846.860
7.052.266
7.189.203
7.326.141
7.913.136
8.150.530
8.308.793
8.467.055
13.478.226
13.882.572
14.152.137
14.421.701
7.557.975
7.784.715
7.935.874
8.087.034
10.125.325
10.429.085
10.631.592
10.834.098
20.626.248
21.245.035
21.657.560
22.070.085
4.723.589
4.865.297
4.959.769
5.054.241
17.545.994
18.072.374
18.423.294
18.774.214
21.462.095
22.105.958
22.535.200
22.964.442
463
M-1-03-i
464
M-1-03-ii
465
M-1-03-iii
466
M-1-04-i
467
M-1-04-ii
468
M-1-04-iii
469
M-1-05-i
470
M-1-05-ii
471
M-1-05-iii
472
M-1-07-i
473
M-1-07-ii
474
M-1-07-iii
475
M-1-10-i
476
M-1-10-ii
477
M-1-10-iii


TULANG WAJAH RINGAN
TULANG WAJAH SEDANG
TULANG WAJAH BERAT
- 190 No
Kode
INA-CBG
478
M-1-20-i
479
M-1-20-ii
480
M-1-20-iii
481
M-1-30-i
482
Deskripsi (INA-CBG)
SENDI MAYOR RINGAN
SENDI MAYOR SEDANG
SENDI MAYOR BERAT
Regional 1
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
4.672.850
4.813.036
4.906.493
4.999.950
6.670.074
6.870.177
7.003.578
7.136.980
12.965.171
13.354.126
13.613.429
13.872.733
2.795.063
2.878.915
2.934.816
2.990.717
M-1-30-ii
5.775.311
5.948.571
6.064.077
6.179.583
483
M-1-30-iii
PROSEDUR KAKI BERAT
8.615.547
8.874.013
9.046.324
9.218.635
484
M-1-40-i
2.824.194
2.908.920
2.965.404
3.021.888
485
M-1-40-ii
5.198.494
5.354.448
5.458.418
5.562.388
486
M-1-40-iii
9.097.364
9.370.285
9.552.232
9.734.179
487
M-1-50-i
3.740.289
3.852.498
3.927.304
4.002.109
488
M-1-50-ii
7.529.290
7.755.169
7.905.754
8.056.340
489
M-1-50-iii
10.396.987
10.708.897
10.916.837
11.124.776
2.822.738
2.907.420
2.963.875
3.020.330
5.651.140
5.820.674
5.933.697
6.046.720
9.834.982
10.130.032
10.326.732
10.523.431
3.781.334
3.894.774
3.970.401
4.046.027
7.715.794
7.947.268
8.101.584
8.255.900
12.438.792
12.811.956
13.060.732
13.309.508

RINGAN
SEDANG
BERAT

SELAIN KAKI (BERAT)
490
M-1-60-i
491
M-1-60-ii
492
M-1-60-iii
493
M-1-70-i
494
M-1-70-ii
495
M-1-70-iii
496
M-1-80-i
3.046.732
3.138.134
3.199.068
3.260.003
497
M-1-80-ii
4.606.036
4.744.217
4.836.337
4.928.458
498
M-1-80-iii
10.604.287
10.922.416
11.134.501
11.346.587
499
M-4-10-i
1.929.531
1.987.417
2.026.008
2.064.598
500
M-4-10-ii
2.943.980
3.032.299
3.091.179
3.150.059
501
M-4-10-iii
FRAKTUR FEMUR BERAT
6.251.386
6.438.927
6.563.955
6.688.983
502
M-4-11-i
2.553.636
2.630.245
2.681.318
2.732.391
503
M-4-11-ii
5.858.422
6.034.175
6.151.343
6.268.512
504
M-4-11-iii
10.398.562
10.710.519
10.918.490
11.126.461
505
M-4-12-i
1.929.531
1.987.417
2.026.008
2.064.598
506
M-4-12-ii
3.510.780
3.616.103
3.686.319
3.756.534
507
M-4-12-iii
7.031.173
7.242.108
7.382.732
7.523.355
508
M-4-13-i
3.562.085
3.668.947
3.740.189
3.811.431

PANGGUL RINGAN
PANGGUL SEDANG
PANGGUL BERAT
PELVIS RINGAN
PELVIS SEDANG
PELVIS BERAT
- 191 No
Kode
INA-CBG
509
M-4-13-ii
510
M-4-13-iii
511
M-4-14-i
512
Deskripsi (INA-CBG)
Regional 1
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
4.823.828
4.968.543
5.065.019
5.161.496
10.596.310
10.914.199
11.126.126
11.338.052
3.859.062
3.974.834
4.052.015
4.129.197
M-4-14-ii
5.010.098
5.160.401
5.260.602
5.360.804
513
M-4-14-iii
OSTEOMIELITIS BERAT
7.504.586
7.729.724
7.879.815
8.029.907
514
M-4-15-i
2.407.642
2.479.871
2.528.024
2.576.177
515
M-4-15-ii
3.210.392
3.306.704
3.370.912
3.435.120
516
M-4-15-iii
8.200.507
8.446.523
8.610.533
8.774.543
517
M-4-16-i
2.411.914
2.484.271
2.532.510
2.580.748
518
M-4-16-ii
3.859.062
3.974.834
4.052.015
4.129.197
519
M-4-16-iii
7.175.650
7.390.920
7.534.433
7.677.946
2.411.914
2.484.271
2.532.510
2.580.748
3.376.680
3.477.980
3.545.513
3.613.047
4.715.712
4.857.184
4.951.498
5.045.812
2.827.138
2.911.952
2.968.495
3.025.037
3.859.062
3.974.834
4.052.015
4.129.197
4.794.661
4.938.500
5.034.394
5.130.287
2.102.015
2.165.076
2.207.116
2.249.156
3.540.467
3.646.681
3.717.490
3.788.299
6.914.793
7.122.237
7.260.533
7.398.829
1.929.531
1.987.417
2.026.008
2.064.598
2.894.297
2.981.126
3.039.012
3.096.897
3.207.563
3.303.790
3.367.941
3.432.092
1.929.531
1.987.417
2.026.008
2.064.598
2.518.523
2.594.079
2.644.450
2.694.820
6.139.097
6.323.270
6.446.052
6.568.834

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
RINGAN
SEDANG
BERAT
ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
520
M-4-17-i
521
M-4-17-ii
522
M-4-17-iii
523
M-4-18-i
524
M-4-18-ii
525
M-4-18-iii
526
M-4-19-i
527
M-4-19-ii
528
M-4-19-iii
529
M-4-20-i
530
M-4-20-ii
531
M-4-20-iii
532
M-4-21-i
533
M-4-21-ii
534
M-4-21-iii
535
N-1-01-i
5.220.789
5.377.413
5.481.829
5.586.245
536
N-1-01-ii
7.061.000
7.272.830
7.414.050
7.555.270
537
N-1-01-iii
14.971.420
15.420.563
15.719.991
16.019.419
538
N-1-11-i
7.202.482
7.418.556
7.562.606
7.706.656
539
N-1-11-ii
9.741.194
10.033.430
10.228.254
10.423.078

RINGAN
SEDANG
- 192 No
Kode
INA-CBG
Deskripsi (INA-CBG)
540
N-1-11-iii
541
N-1-12-i
542
N-1-12-ii
543
N-1-12-iii
544
N-1-20-i
545
N-1-20-ii
546
N-1-20-iii
Regional 1
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
20.654.230
21.273.857
21.686.941
22.100.026
3.898.870
4.015.836
4.093.814
4.171.791
9.070.446
9.342.559
9.523.968
9.705.377
16.531.452
17.027.396
17.358.025
17.688.654
5.278.762
5.437.125
5.542.700
5.648.276
10.465.909
10.779.886
10.989.205
11.198.523
11.972.051
12.331.213
12.570.654
12.810.095
6.280.020
6.468.420
6.594.020
6.719.621
9.543.273
9.829.571
10.020.437
10.211.302
10.985.881
11.315.457
11.535.175
11.754.892
5.658.912
5.828.680
5.941.858
6.055.036
7.670.857
7.900.983
8.054.400
8.207.817
8.921.429
9.189.072
9.367.500
9.545.929
2.411.914
2.484.271
2.532.510
2.580.748
3.229.620
3.326.509
3.391.101
3.455.694
7.069.057
7.281.129
7.422.510
7.563.891


URIN BAWAH RINGAN
URIN BAWAH SEDANG
URIN BAWAH BERAT
RINGAN
SEDANG
BERAT
GINJAL RINGAN
GINJAL SEDANG
GINJAL BERAT
547
N-1-30-i
548
N-1-30-ii
549
N-1-30-iii
550
N-1-40-i
551
N-1-40-ii
552
N-1-40-iii
553
N-4-10-i
554
N-4-10-ii
555
N-4-10-iii
556
N-4-11-i
1.847.051
1.902.463
1.939.404
1.976.345
557
N-4-11-ii
3.121.472
3.215.116
3.277.546
3.339.975
558
N-4-11-iii
3.617.871
3.726.407
3.798.764
3.871.122
559
N-4-12-i
1.929.531
1.987.417
2.026.008
2.064.598
560
N-4-12-ii
2.894.297
2.981.126
3.039.012
3.096.897
561
N-4-12-iii
4.805.484
4.949.648
5.045.758
5.141.868
562
N-4-13-i
BATU URIN RINGAN
2.545.645
2.622.014
2.672.927
2.723.840
563
N-4-13-ii
BATU URIN SEDANG
3.069.090
3.161.163
3.222.545
3.283.927
564
N-4-13-iii
BATU URIN BERAT
7.558.327
7.785.077
7.936.244
8.087.410
565
N-4-14-i
1.671.332
1.721.472
1.754.898
1.788.325
566
N-4-14-ii
2.573.640
2.650.850
2.702.322
2.753.795
567
N-4-14-iii
4.173.624
4.298.833
4.382.306
4.465.778
568
N-4-15-i
2.479.551
2.553.937
2.603.528
2.653.119
569
N-4-15-ii
3.402.715
3.504.797
3.572.851
3.640.905

(RINGAN)
(SEDANG)
(BERAT)
SALURAN URIN RINGAN
SALURAN URIN SEDANG
- 193 No
Kode
INA-CBG
570
N-4-15-iii
571
N-4-16-i
572
N-4-16-ii
573
N-4-16-iii
574
O-6-10-i
575
O-6-10-ii
576
O-6-10-iii
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
584
Deskripsi (INA-CBG)
SALURAN URIN BERAT
RINGAN
SEDANG
BERAT
&KURET RINGAN
KURET SEDANG
KURET BERAT
Regional 1
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
3.883.112
3.999.605
4.077.268
4.154.930
3.218.114
3.314.658
3.379.020
3.443.382
3.859.062
3.974.834
4.052.015
4.129.197
8.115.034
8.358.485
8.520.786
8.683.086
4.751.704
4.894.256
4.989.290
5.084.324
5.275.116
5.433.370
5.538.872
5.644.374
5.913.469
6.090.873
6.209.142
6.327.411
2.483.411
2.557.913
2.607.581
2.657.249
3.185.989
3.281.569
3.345.289
3.409.008
5.399.263
5.561.241
5.669.226
5.777.211
2.162.566
2.227.443
2.270.694
2.313.945
2.597.236
2.675.153
2.727.098
2.779.042
3.263.055
3.360.946
3.426.208
3.491.469
2.167.281
2.232.299
2.275.645
2.318.990
O-6-13-ii
3.194.146
3.289.971
3.353.854
3.417.737
585
O-6-13-iii
3.774.988
3.888.237
3.963.737
4.039.237
586
P-8-01-i
48.481.088
49.935.521
50.905.143
51.874.764
587
P-8-01-ii
59.987.763
61.787.396
62.987.151
64.186.906
588
P-8-01-iii
70.408.818
72.521.082
73.929.258
75.337.435
589
P-8-02-i
58.738.622
60.500.781
61.675.553
62.850.326
590
P-8-02-ii
67.379.246
69.400.623
70.748.208
72.095.793
591
P-8-02-iii
76.985.606
79.295.174
80.834.886
82.374.598
592
P-8-03-i
3.249.059
3.346.530
3.411.511
3.476.493
593
P-8-03-ii
4.548.682
4.685.142
4.776.116
4.867.090
594
P-8-03-iii
7.165.206
7.380.162
7.523.466
7.666.770
595
P-8-04-i
29.016.375
29.886.866
30.467.193
31.047.521
596
P-8-04-ii
37.656.998
38.786.708
39.539.848
40.292.988
597
P-8-04-iii
53.990.657
55.610.377
56.690.190
57.770.003
598
P-8-05-i
15.778.164
16.251.509
16.567.072
16.882.635

- 194 No
Kode
INA-CBG
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii
603
P-8-06-iii
604
P-8-07-i
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
614
P-8-11-ii
615
P-8-11-iii
616
P-8-12-i
617
P-8-12-ii
618
P-8-12-iii
619
P-8-13-i
620
P-8-13-ii
621
P-8-13-iii
622
P-8-14-i
623
P-8-14-ii
624
P-8-14-iii
625
P-8-15-i
626
P-8-15-ii
Deskripsi (INA-CBG)
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
RINGAN
SEDANG
BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
ASPIRASI RINGAN
ASPIRASI SEDANG
Regional 1
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
22.363.420
23.034.323
23.481.591
23.928.859
32.949.497
33.937.982
34.596.972
35.255.962
2.599.247
2.677.224
2.729.209
2.781.194
6.540.386
6.736.598
6.867.405
6.998.213
12.165.864
12.530.840
12.774.157
13.017.475
4.548.682
4.685.142
4.776.116
4.867.090
12.753.409
13.136.012
13.391.080
13.646.148
16.895.104
17.401.957
17.739.860
18.077.762
3.296.347
3.395.237
3.461.164
3.527.091
4.679.628
4.820.017
4.913.610
5.007.202
6.606.198
6.804.384
6.936.508
7.068.632
2.045.050
2.106.401
2.147.302
2.188.203
2.962.552
3.051.429
3.110.680
3.169.931
5.816.363
5.990.854
6.107.181
6.223.509
5.759.730
5.932.521
6.047.716
6.162.911
12.262.306
12.630.176
12.875.422
13.120.668
12.519.204
12.894.780
13.145.164
13.395.548
2.717.289
2.798.808
2.853.154
2.907.500
4.224.913
4.351.660
4.436.159
4.520.657
4.984.504
5.134.039
5.233.729
5.333.419
1.404.442
1.446.575
1.474.664
1.502.752
2.598.908
2.676.875
2.728.854
2.780.832
3.886.945
4.003.553
4.081.292
4.159.031
2.566.061
2.643.043
2.694.364
2.745.685
5.239.170
5.396.345
5.501.128
5.605.912
5.747.350
5.919.770
6.034.717
6.149.664
1.929.758
1.987.650
2.026.246
2.064.841
3.857.078
3.972.791
4.049.932
4.127.074
- 195 No
Kode
INA-CBG
627
P-8-15-iii
628
P-8-16-i
629
P-8-16-ii
630
P-8-16-iii
631
P-8-17-i
632
P-8-17-ii
633
P-8-17-iii
634
S-4-10-i
635
S-4-10-ii
636
S-4-10-iii
637
S-4-11-i
638
Deskripsi (INA-CBG)
ASPIRASI BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
Regional 1
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
4.530.736
4.666.658
4.757.272
4.847.887
1.746.887
1.799.293
1.834.231
1.869.169
2.478.034
2.552.375
2.601.935
2.651.496
3.216.609
3.313.108
3.377.440
3.441.772
1.152.941
1.187.530
1.210.589
1.233.647
3.829.682
3.944.572
4.021.166
4.097.759
7.729.968
7.961.867
8.116.467
8.271.066
1.929.531
1.987.417
2.026.008
2.064.598
2.411.914
2.484.271
2.532.510
2.580.748
3.135.074
3.229.126
3.291.828
3.354.529
1.205.957
1.242.136
1.266.255
1.290.374
S-4-11-ii
1.835.489
1.890.554
1.927.264
1.963.974
639
S-4-11-iii
2.969.501
3.058.586
3.117.976
3.177.366
640
S-4-12-i
1.447.148
1.490.563
1.519.506
1.548.449
641
S-4-12-ii
1.929.531
1.987.417
2.026.008
2.064.598
642
S-4-12-iii
3.768.527
3.881.583
3.956.953
4.032.324
1.929.531
1.987.417
2.026.008
2.064.598
3.410.978
3.513.308
3.581.527
3.649.747
6.945.186
7.153.541
7.292.445
7.431.349
1.175.628
1.210.897
1.234.409
1.257.922
2.497.428
2.572.351
2.622.299
2.672.248
4.736.013
4.878.093
4.972.814
5.067.534
889.138
915.812
933.595
951.378
1.678.107
1.728.450
1.762.012
1.795.574
2.173.538
2.238.744
2.282.215
2.325.686

PASIEN RINGAN
PASIEN SEDANG
PASIEN BERAT
643
S-4-13-i
644
S-4-13-ii
645
S-4-13-iii
646
S-4-14-i
647
S-4-14-ii
648
S-4-14-iii
649
S-4-15-i
650
S-4-15-ii
651
S-4-15-iii
652
S-4-16-i
LUKA BAKAR RINGAN
3.376.680
3.477.980
3.545.513
3.613.047
653
S-4-16-ii
LUKA BAKAR SEDANG
4.768.971
4.912.041
5.007.420
5.102.799
654
S-4-16-iii
LUKA BAKAR BERAT
8.515.739
8.771.211
8.941.526
9.111.841
655
S-4-17-i
1.800.512
1.854.527
1.890.537
1.926.548
656
S-4-17-ii
2.411.914
2.484.271
2.532.510
2.580.748
657
S-4-17-iii
3.933.102
4.051.095
4.129.757
4.208.419
658
T-1-10-i
1.858.625
1.914.384
1.951.556
1.988.729

- 196 No
Kode
INA-CBG
659
T-1-10-ii
660
T-1-10-iii
661
T-4-10-i
662
T-4-10-ii
663
T-4-10-iii
664
T-4-11-i
665
T-4-11-ii
666
T-4-11-iii
667
T-4-12-i
668
T-4-12-ii
669
T-4-12-iii
670
U-1-10-i
671
Deskripsi (INA-CBG)
DOKTER RINGAN
DOKTER SEDANG
DOKTER BERAT
Regional 1
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
2.496.007
2.570.888
2.620.808
2.670.728
4.541.051
4.677.282
4.768.103
4.858.924
813.016
837.406
853.666
869.927
1.549.427
1.595.910
1.626.899
1.657.887
2.252.447
2.320.020
2.365.069
2.410.118
804.026
828.147
844.227
860.308
1.265.308
1.303.267
1.328.573
1.353.879
2.038.038
2.099.179
2.139.940
2.180.701
1.688.340
1.738.990
1.772.757
1.806.524
2.551.833
2.628.388
2.679.424
2.730.461
3.969.735
4.088.827
4.168.221
4.247.616
1.797.083
1.850.996
1.886.937
1.922.879
U-1-10-ii
3.667.058
3.777.070
3.850.411
3.923.752
672
U-1-10-iii
15.835.098
16.310.151
16.626.853
16.943.555
673
U-1-11-i
674
U-1-11-ii
675
U-1-11-iii
676

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
7.797.740
8.031.673
8.187.627
8.343.582
10.396.987
10.708.897
10.916.837
11.124.776
17.467.864
17.991.900
18.341.257
18.690.615
U-1-12-i
4.765.283
4.908.242
5.003.548
5.098.853
677
U-1-12-ii
11.696.611
12.047.509
12.281.441
12.515.373
678
U-1-12-iii
15.188.270
15.643.919
15.947.684
16.251.449
679
U-1-13-i
5.198.494
5.354.448
5.458.418
5.562.388
680
U-1-13-ii
5.865.311
6.041.271
6.158.577
6.275.883
681
U-1-13-iii
11.309.974
11.649.274
11.875.473
12.101.673
682
U-1-14-i
2.868.365
2.954.416
3.011.784
3.069.151
683
U-1-14-ii
3.520.061
3.625.663
3.696.064
3.766.465
684
U-1-14-iii
4.171.371
4.296.513
4.379.940
4.463.367
685
U-1-15-i
1.684.700
1.735.241
1.768.935
1.802.629
686
U-1-15-ii
2.393.842
2.465.657
2.513.534
2.561.410
687
U-1-15-iii
4.717.161
4.858.676
4.953.019
5.047.362
688
U-1-20-i
4.357.586
4.488.314
4.575.465
4.662.617
689
U-1-20-ii
7.756.503
7.989.198
8.144.328
8.299.458


- 197 No
Kode
INA-CBG
Deskripsi (INA-CBG)
690
U-1-20-iii

691
U-1-30-i
692
U-1-30-ii
693
U-1-30-iii
Regional 1
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
19.135.576
19.709.643
20.092.355
20.475.066
3.738.049
3.850.190
3.924.951
3.999.712
5.046.366
5.197.757
5.298.684
5.399.612
9.892.328
10.189.098
10.386.945
10.584.791
3.479.499
3.583.884
3.653.474
3.723.064
8.722.374
8.984.045
9.158.492
9.332.940
12.724.044
13.105.765
13.360.246
13.614.727

DAN TELINGA RINGAN
DAN TELINGA SEDANG
DAN TELINGA BERAT
694
U-4-10-i
695
U-4-10-ii
696
U-4-10-iii
697
U-4-11-i
1.929.531
1.987.417
2.026.008
2.064.598
698
U-4-11-ii
2.894.297
2.981.126
3.039.012
3.096.897
699
U-4-11-iii
4.002.801
4.122.885
4.202.941
4.282.997
700
U-4-12-i
1.929.531
1.987.417
2.026.008
2.064.598
701
U-4-12-ii
2.249.389
2.316.871
2.361.858
2.406.846
702
U-4-12-iii
3.576.426
3.683.719
3.755.247
3.826.776
1.895.622
1.952.491
1.990.403
2.028.316
2.203.772
2.269.885
2.313.960
2.358.036
2.502.221
2.577.288
2.627.332
2.677.377

703
U-4-13-i
704
U-4-13-ii
705
U-4-13-iii
706
U-4-14-i
2.411.914
2.484.271
2.532.510
2.580.748
707
U-4-14-ii
2.894.297
2.981.126
3.039.012
3.096.897
708
U-4-14-iii
4.848.449
4.993.903
5.090.872
5.187.841
709
U-4-15-i
1.929.531
1.987.417
2.026.008
2.064.598
710
U-4-15-ii
2.411.914
2.484.271
2.532.510
2.580.748
711
U-4-15-iii
3.377.334
3.478.654
3.546.201
3.613.747
712
V-1-10-i
5.640.659
5.809.879
5.922.692
6.035.505
713
V-1-10-ii
6.498.117
6.693.061
6.823.023
6.952.985
714
V-1-10-iii
12.346.422
12.716.815
12.963.744
13.210.672
715
V-1-11-i
6.498.117
6.693.061
6.823.023
6.952.985
716
V-1-11-ii
7.252.008
7.469.568
7.614.608
7.759.648
717
V-1-11-iii
10.739.113
11.061.286
11.276.069
11.490.851
718
V-1-12-i
3.509.506
3.614.791
3.684.981
3.755.171
719
V-1-12-ii
13.412.165
13.814.530
14.082.773
14.351.016
720
V-1-12-iii
15.659.924
16.129.722
16.442.921
16.756.119
721
V-1-13-i
5.319.273
5.478.851
5.585.237
5.691.622
722
V-1-13-ii
10.108.145
10.411.390
10.613.553
10.815.716

KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

- 198 No
Kode
INA-CBG
723
V-1-13-iii
724
V-1-14-i
725
V-1-14-ii
726
V-1-14-iii
727
V-1-15-i
728
Deskripsi (INA-CBG)
NON KOMPLEK (BERAT)
Regional 1
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
15.595.481
16.063.345
16.375.255
16.687.165
6.412.446
6.604.819
6.733.068
6.861.317
9.326.353
9.606.143
9.792.670
9.979.197
12.677.820
13.058.154
13.311.711
13.565.267
3.023.111
3.113.804
3.174.267
3.234.729
V-1-15-ii
5.758.438
5.931.191
6.046.360
6.161.529
729
V-1-15-iii
10.123.224
10.426.921
10.629.385
10.831.850
730
V-4-10-i
4.867.972
5.014.011
5.111.371
5.208.730
731
V-4-10-ii
6.287.567
6.476.194
6.601.946
6.727.697
732
V-4-10-iii
12.016.645
12.377.144
12.617.477
12.857.810
733
V-4-11-i
2.475.546
2.549.812
2.599.323
2.648.834
734
V-4-11-ii
3.617.168
3.725.683
3.798.027
3.870.370
735
V-4-11-iii
5.968.088
6.147.131
6.266.493
6.385.854
736
W-1-01-i
7.279.318
7.497.697
7.643.284
7.788.870
737
W-1-01-ii
8.767.593
9.030.621
9.205.973
9.381.324
738
W-1-01-iii
19.365.871
19.946.847
20.334.165
20.721.482
739
W-1-10-i
2.027.281
2.088.100
2.128.645
2.169.191
740
W-1-10-ii
3.783.239
3.896.737
3.972.401
4.048.066
741
W-1-10-iii
6.188.179
6.373.825
6.497.588
6.621.352
2.105.671
2.168.841
2.210.955
2.253.068
4.061.053
4.182.885
4.264.106
4.345.327
7.797.740
8.031.673
8.187.627
8.343.582
1.913.319
1.970.718
2.008.985
2.047.251
2.175.407
2.240.669
2.284.177
2.327.685
3.341.699
3.441.950
3.508.784
3.575.618
2.277.301
2.345.620
2.391.166
2.436.712
2.472.493
2.546.668
2.596.118
2.645.567
3.321.014
3.420.645
3.487.065
3.553.485

RINGAN
SEDANG
BERAT

SERVIK RINGAN
SERVIK SEDANG
SERVIK BERAT
ENDOSKOP RINGAN
ENDOSKOP SEDANG
ENDOSKOP BERAT
742
W-1-11-i
743
W-1-11-ii
744
W-1-11-iii
745
W-1-12-i
746
W-1-12-ii
747
W-1-12-iii
748
W-1-13-i
749
W-1-13-ii
750
W-1-13-iii
751
W-1-20-i
6.204.997
6.391.147
6.515.247
6.639.347
752
W-1-20-ii
8.728.260
8.990.108
9.164.673
9.339.238
753
W-1-20-iii
11.026.252
11.357.040
11.577.565
11.798.090
W-1-30-i

RINGAN
3.387.306
3.488.926
3.556.672
3.624.418
754
- 199 No
Kode
INA-CBG
755
W-1-30-ii
756
W-1-30-iii
757
W-4-10-i
758
Deskripsi (INA-CBG)
SEDANG
BERAT
Regional 1
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
5.402.929
5.565.017
5.673.075
5.781.134
14.367.717
14.798.749
15.086.103
15.373.457
2.526.082
2.601.864
2.652.386
2.702.908
W-4-10-ii
3.414.283
3.516.711
3.584.997
3.653.282
759
W-4-10-iii
7.718.125
7.949.668
8.104.031
8.258.393
760
W-4-11-i
2.411.914
2.484.271
2.532.510
2.580.748
761
W-4-11-ii
3.859.062
3.974.834
4.052.015
4.129.197
762
W-4-11-iii
4.689.904
4.830.602
4.924.400
5.018.198
1.929.531
1.987.417
2.026.008
2.064.598
2.653.105
2.732.698
2.785.761
2.838.823
2.957.918
3.046.655
3.105.814
3.164.972

763
W-4-12-i
764
W-4-12-ii
765
W-4-12-iii
766
W-4-13-i
ABORTUS RINGAN
1.058.178
1.089.923
1.111.087
1.132.250
767
W-4-13-ii
ABORTUS SEDANG
1.447.148
1.490.563
1.519.506
1.548.449
768
W-4-13-iii
ABORTUS BERAT
1.929.531
1.987.417
2.026.008
2.064.598
769
W-4-14-i
1.447.148
1.490.563
1.519.506
1.548.449
770
W-4-14-ii
1.861.266
1.917.104
1.954.330
1.991.555
771
W-4-14-iii
2.342.043
2.412.304
2.459.145
2.505.986
772
W-4-15-i
1.206.753
1.242.956
1.267.091
1.291.226
773
W-4-15-ii
1.342.140
1.382.404
1.409.247
1.436.089
774
W-4-15-iii
1.858.320
1.914.069
1.951.236
1.988.402
775
W-4-16-i
1.447.148
1.490.563
1.519.506
1.548.449
776
W-4-16-ii
1.929.531
1.987.417
2.026.008
2.064.598
777
W-4-16-iii
2.630.653
2.709.573
2.762.186
2.814.799
778
W-4-17-i
1.181.967
1.217.426
1.241.065
1.264.704
779
W-4-17-ii
1.929.531
1.987.417
2.026.008
2.064.598
780
W-4-17-iii
3.650.289
3.759.798
3.832.804
3.905.809
781
Z-4-10-i
REHABILITASI RINGAN
3.310.847
3.410.172
3.476.389
3.542.606
782
Z-4-10-ii
REHABILITASI SEDANG
4.394.671
4.526.512
4.614.405
4.702.298
783
Z-4-10-iii
REHABILITASI BERAT
6.243.050
6.430.341
6.555.202
6.680.063
784
Z-4-11-i
2.890.005
2.976.705
3.034.505
3.092.305
785
Z-4-11-ii
3.478.927
3.583.295
3.652.874
3.722.452
786
Z-4-11-iii
5.504.281
5.669.410
5.779.496
5.889.581
1.447.148
1.490.563
1.519.506
1.548.449
2.948.517
3.036.973
3.095.943
3.154.913
3.747.098
3.859.511
3.934.453
4.009.395
787
Z-4-12-i
788
Z-4-12-ii
789
Z-4-12-iii

b. RawatJalan
No
Kode
INA-CBG
B-2-10-0
B-2-11-0
- 200 -
Deskripsi (INA-CBG)
LAPAROSKOPI
PANKREAS
LAPAROSKOPI
EMPEDU
Regional 1
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
800.166
824.171
840.174
856.178
1.037.940
1.069.079
1.089.837
1.110.596
1.930.187
1.988.093
2.026.696
2.065.300
1.595.112
1.642.966
1.674.868
1.706.770
1.332.579
1.372.556
1.399.208
1.425.859
467.208
481.224
490.568
499.913
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
1.041.813
1.073.067
1.093.903
1.114.739
B-3-12-0

214.058
220.480
224.761
229.042
C-3-10-0
583.921
601.438
613.117
624.795
10
C-3-11-0

KANDUNG KEMIH
923.492
951.197
969.667
988.137
11
C-3-12-0
209.354
215.634
219.822
224.009
12
C-3-13-0
203.297
209.396
213.462
217.528
13
C-3-14-0
1.730.670
1.782.590
1.817.203
1.851.817
14
C-3-15-0
1.586.228
1.633.815
1.665.539
1.697.264
15
C-3-16-0
359.718
370.510
377.704
384.899
16
C-3-17-0

LEHER
238.627
245.785
250.558
255.330
17
C-3-18-0
105.797
108.971
111.087
113.202
18
C-3-19-0

MYELOMA ATAU TESTIS
149.618
154.107
157.099
160.091
19
C-3-20-0
2.979.648
3.069.038
3.128.631
3.188.224
20
C-3-21-0
170.741
175.863
179.278
182.693
21
C-3-22-0
749.644
772.133
787.126
802.119
22
C-3-23-0
121.426
125.069
127.497
129.926
23
D-2-10-0

TULANG
1.028.737
1.059.599
1.080.174
1.100.749
24
D-2-11-0
PROSEDUR LIMPA
1.288.155
1.326.799
1.352.563
1.378.326
25
D-2-21-0
1.080.397
1.112.809
1.134.417
1.156.025
26
D-2-22-0
237.115
244.228
248.970
253.713
27
D-3-10-0
171.748
176.900
180.335
183.770
28
D-3-11-0
445.907
459.284
468.203
477.121
29
E-2-10-0
264.509
272.444
277.734
283.024
30
E-2-21-0
191.760
197.513
201.348
205.183
31
E-2-22-0
191.760
197.513
201.348
205.183

OVARIUM
GASTROINTESTINAL
GINJAL ATAU PROSTAT

TYMUS
TYMUS
TULANG
PEMBENTUK DARAH
PARATIROID
THYROGLOSSAL
- 201 No
Kode
INA-CBG
Deskripsi (INA-CBG)
Regional 1
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
32
E-3-10-0

ENDOKRIN
33
F-3-10-0
TERAPI SHOCK
311.084
320.416
326.638
332.860
34
F-5-10-0
381.178
392.614
400.237
407.861
35
F-5-11-0
TERAPI KELOMPOK
251.352
258.893
263.920
268.947
36
F-5-12-0
321.648
331.297
337.730
344.163
37
F-5-13-0
272.414
280.587
286.035
291.483
38
F-5-14-0
182.753
188.236
191.891
195.546
39
F-5-15-0
171.446
176.590
180.019
183.447
40
F-5-16-0
178.578
183.935
187.507
191.078
41
G-2-10-0
150.376
154.887
157.895
160.903
42
G-2-11-0
1.303.524
1.342.630
1.368.700
1.394.771
43
G-2-12-0

EKSTRAKRANIAL
1.889.128
1.945.801
1.983.584
2.021.366
44
G-2-13-0
463.445
477.348
486.617
495.886
45
G-2-21-0
845.246
870.603
887.508
904.413
46
G-2-22-0
767.132
790.146
805.489
820.832
47
G-2-31-0
1.265.835
1.303.810
1.329.127
1.354.444
48
G-2-32-0
648.866
668.332
681.309
694.287
49
G-3-10-0
257.539
265.265
270.416
275.567
50
G-3-11-0
342.993
353.282
360.142
367.002
51
G-3-12-0
561.999
578.859
590.099
601.339
52
G-3-13-0
562.063
578.925
590.167
601.408
53
H-2-21-0
737.625
759.754
774.506
789.259
54
H-2-22-0
191.760
197.513
201.348
205.183
55
H-2-23-0
191.760
197.513
201.348
205.183
56
H-2-31-0
1.221.814
1.258.469
1.282.905
1.307.341
57
H-2-32-0
127.162
130.977
133.520
136.064
58
H-2-33-0
191.760
197.513
201.348
205.183
59
H-2-34-0
548.136
564.580
575.542
586.505
60
H-2-35-0
180.623
186.042
189.654
193.267
61
H-2-36-0
974.961
1.004.210
1.023.710
1.043.209
62
H-2-37-0

1.037.889
1.069.026
1.089.784
1.110.542
63
H-3-10-0
361.110
371.943
379.165
386.387
64
H-3-11-0
189.904
195.601
199.399
203.197

AKUT
MENTAL
PROSEDUR KRANIOTOMI

MATA
MATA
MATA
MATA
MATA
223.004
229.694
234.155
238.615
- 202 No
Kode
INA-CBG
65
H-3-12-0
66
H-3-13-0
67
I-2-11-0
68
I-2-12-0
69
I-2-13-0
70
I-2-14-0
71
I-2-15-0
Deskripsi (INA-CBG)
MATA
TORASIK
ABDOMEN
PENGGANTIAN ALAT
DARAH VENA
Regional 1
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
198.269
204.217
208.183
212.148
192.507
198.283
202.133
205.983
2.220.020
2.286.620
2.331.021
2.375.421
1.560.916
1.607.744
1.638.962
1.670.180
1.983.831
2.043.345
2.083.022
2.122.699
3.510.958
3.616.286
3.686.505
3.756.725
211.142
217.476
221.699
225.922
2.217.614
2.284.142
2.328.495
2.372.847
731.084
753.016
767.638
782.259
72
I-2-16-0
73
I-2-17-0
74
I-2-21-0
1.711.683
1.763.033
1.797.267
1.831.500
75
I-2-22-0
1.611.849
1.660.204
1.692.441
1.724.678
76
I-2-23-0
329.860
339.756
346.353
352.950
77
I-2-31-0
2.565.433
2.642.396
2.693.705
2.745.014
78
I-2-32-0
3.354.681
3.455.321
3.522.415
3.589.508
79
I-2-41-0
2.249.355
2.316.835
2.361.822
2.406.809
80
I-2-42-0

LAIN
2.615.247
2.693.704
2.746.009
2.798.314
81
I-3-10-0
PROSEDUR RESUSITASI
331.982
341.942
348.581
355.221
82
I-3-11-0
175.220
180.476
183.981
187.485
83
I-3-12-0
1.018.310
1.048.859
1.069.225
1.089.591
84
I-3-13-0
334.452
344.486
351.175
357.864
85
I-3-14-0
214.373
220.804
225.091
229.379

PACU JANTUNG

KARDIOVASKULAR
PERNAFASAN
PENDEK
189.904
195.601
199.399
203.197
2.697.246
2.778.163
2.832.108
2.886.053
434.795
447.839
456.535
465.231
86
I-3-15-0
87
J-2-10-0
88
J-2-21-0
89
J-2-22-0
2.191.098
2.256.831
2.300.653
2.344.475
90
J-2-31-0
2.842.050
2.927.311
2.984.152
3.040.993
91
J-2-32-0
2.114.957
2.178.405
2.220.704
2.263.004
92
J-3-10-0
439.905
453.102
461.900
470.698
93
J-3-11-0

PADA DADA
1.243.094
1.280.386
1.305.248
1.330.110
94
J-3-12-0
480.266
494.674
504.280
513.885
95
J-3-13-0
706.832
728.037
742.174
756.311
96
J-3-14-0
750.379
772.891
787.898
802.906
- 203 No
Kode
INA-CBG
97
J-3-15-0
658.023
677.763
690.924
704.084
98
J-3-16-0
750.379
772.891
787.898
802.906
99
J-3-17-0
439.905
453.102
461.900
470.698
100
K-2-10-0
551.950
568.509
579.548
590.587
101
K-2-11-0
1.178.639
1.213.999
1.237.571
1.261.144
102
K-2-12-0

904.758
931.900
949.996
968.091
103
K-2-13-0
1.472.542
1.516.718
1.546.169
1.575.620
191.760
197.513
201.348
205.183
191.760
197.513
201.348
205.183
2.464.571
2.538.508
2.587.799
2.637.091
828.710
853.571
870.145
886.719
191.760
197.513
201.348
205.183
Deskripsi (INA-CBG)

PERNAFASAN
KECIL

FEMORALIS
USUS BESAR
ATAS
ATAS
Regional 1
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
104
K-2-14-0
105
K-2-21-0
106
K-2-22-0
107
K-2-31-0
108
K-2-32-0
109
K-2-41-0
912.841
940.226
958.483
976.740
110
K-2-42-0

260.810
268.634
273.850
279.067
111
K-2-51-0
604.904
623.051
635.149
647.247
112
K-2-52-0
329.860
339.756
346.353
352.950
113
K-2-53-0
191.760
197.513
201.348
205.183
114
K-3-10-0

GASTROINTESTINAL
364.906
375.853
383.151
390.450
115
K-3-11-0
219.380
225.961
230.349
234.736
116
K-3-12-0
222.479
229.153
233.603
238.052
117
K-3-13-0
191.760
197.513
201.348
205.183
513.921
529.338
539.617
549.895
248.179
255.625
260.588
265.552
328.854
338.719
345.296
351.873
1.130.610
1.164.529
1.187.141
1.209.753
724.713
746.455
760.949
775.443
327.099
336.912
343.454
349.996
329.860
339.756
346.353
352.950

GASTROINTESTINAL
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
118
K-3-14-0
119
K-3-15-0
120
K-3-16-0
121
L-2-21-0
122
L-2-22-0
123
L-2-31-0
124
L-2-32-0
125
L-2-41-0
987.727
1.017.359
1.037.113
1.056.868
126
L-2-42-0

221.531
228.177
232.608
237.038
127
L-2-51-0
1.478.782
1.523.145
1.552.721
1.582.297
1.131.317
1.165.256
1.187.883
1.210.509
191.760
197.513
201.348
205.183
128
L-2-52-0
129
L-2-53-0

- 204 No
Kode
INA-CBG
Deskripsi (INA-CBG)
130
L-3-10-0
260.810
268.634
273.850
279.067
131
L-3-11-0
253.264
260.862
265.928
270.993
132
L-3-12-0
192.885
198.672
202.529
206.387
1.512.902
1.558.289
1.588.547
1.618.805
1.354.908
1.395.555
1.422.653
1.449.752
329.860
339.756
346.353
352.950

DAN WAJAH
PAHA
PAHA
Regional 1
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
133
M-2-10-0
134
M-2-21-0
135
M-2-22-0
136
M-2-31-0
PROSEDUR BUNION
822.971
847.660
864.119
880.578
137
M-2-32-0
260.810
268.634
273.850
279.067
138
M-2-41-0

TULANG
260.810
268.634
273.850
279.067
139
M-2-42-0
89.882
92.579
94.376
96.174
140
M-2-51-0
191.760
197.513
201.348
205.183
141
M-2-52-0
191.760
197.513
201.348
205.183
142
M-2-61-0
PROSEDUR ARTROSKOPI
939.915
968.113
986.911
1.005.709
143
M-2-62-0
191.760
197.513
201.348
205.183
144
M-2-63-0
945.000
973.350
992.250
1.011.150
145
M-2-64-0
1.288.785
1.327.448
1.353.224
1.379.000
146
M-2-65-0
191.760
197.513
201.348
205.183
147
M-2-71-0
951.462
980.006
999.035
1.018.064
148
M-2-72-0
918.201
945.747
964.111
982.475
149
M-2-81-0
1.369.234
1.410.311
1.437.695
1.465.080
150
M-2-82-0
994.660
1.024.500
1.044.393
1.064.287
151
M-2-83-0
191.760
197.513
201.348
205.183
152
M-2-84-0
191.760
197.513
201.348
205.183
153
M-3-10-0
547.320
563.739
574.686
585.632
154
M-3-11-0
303.455
312.559
318.628
324.697
155
M-3-12-0
686.241
706.828
720.553
734.278
156
M-3-13-0
223.733
230.445
234.920
239.394
157
M-3-14-0

TERTUTUP
382.398
393.870
401.517
409.165
158
M-3-15-0
168.470
173.524
176.893
180.262
159
M-3-16-0

191.760
197.513
201.348
205.183
160
M-3-17-0
209.354
215.634
219.822
224.009
161
N-2-11-0
2.533.336
2.609.336
2.660.002
2.710.669
162
N-2-12-0

1.465.510
1.509.475
1.538.785
1.568.095

TULANG
WAJAH
WAJAH
BAWAH
BAWAH

PERGELANGAN TANGAN
PERGELANGAN TANGAN
MUSKULOSKELETAL
SKELETAL
- 205 No
Kode
INA-CBG
Deskripsi (INA-CBG)
163
N-2-21-0

164
N-2-22-0
165
N-2-23-0
166
N-2-24-0
167
N-2-31-0
168
N-2-32-0
169
N-2-41-0
170
N-2-42-0
171
N-3-10-0
172
N-3-11-0
173
N-3-12-0
174
N-3-13-0
175
N-3-14-0
176
N-3-15-0
Regional 1
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
1.457.785
1.501.518
1.530.674
1.559.830
329.860
339.756
346.353
352.950
329.860
339.756
346.353
352.950
1.065.997
1.097.977
1.119.297
1.140.617
897.397
924.319
942.267
960.214
329.860
339.756
346.353
352.950
329.860
339.756
346.353
352.950
557.857
574.592
585.749
596.907
329.860
339.756
346.353
352.950
382.190
393.656
401.300
408.943
295.335
304.195
310.102
316.008
329.860
339.756
346.353
352.950
283.827
292.341
298.018
303.695
727.803
749.637
764.193
778.749
121.512
125.157
127.587
130.018
669.197
689.273
702.657
716.041
243.677
250.988
255.861
260.735
135.425
139.488
142.196
144.905
180.623
186.042
189.654
193.267

DAN URETHRA
URETHRA
TRANSURETHRA
TRANSURETHRA
SALURAN KEMIH
KEMIH
KEMIH
PROSEDUR DIALISIS
CAESAR
VAGINAL/JALAN LAHIR
177
O-7-10-0
178
O-7-11-0
179
O-7-12-0
180
O-7-13-0
181
P-9-10-0
182
P-9-11-0
180.623
186.042
189.654
193.267
183
P-9-12-0
180.623
186.042
189.654
193.267
184
P-9-13-0
180.623
186.042
189.654
193.267
180.623
186.042
189.654
193.267
115.133
118.587
120.890
123.192
180.623
186.042
189.654
193.267

ASPIRASI
185
P-9-14-0
186
P-9-15-0
187
P-9-16-0
188
P-9-17-0
179.846
185.242
188.839
192.436
189
Q-5-10-0
235.410
242.472
247.180
251.888
190
Q-5-11-0
176.433
181.726
185.255
188.783
191
Q-5-12-0
GIGI
155.503
160.169
163.279
166.389
192
Q-5-13-0
MEDICAL CHECK-UP
118.176
121.721
124.085
126.448
193
Q-5-14-0
130.032
133.933
136.534
139.134
194
Q-5-15-0
89.423
92.106
93.894
95.683
- 206 No
Kode
INA-CBG
195
Q-5-16-0
VAKSINASI
196
Q-5-17-0
PASANG INFUS
197
Q-5-18-0
198
Deskripsi (INA-CBG)
Regional 1
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
101.069
104.101
106.122
108.143
87.422
90.044
91.793
93.541
164.555
169.492
172.783
176.074
Q-5-19-0
183.963
189.481
193.161
196.840
199
Q-5-20-0
ABORSI MENGANCAM
123.304
127.003
129.469
131.935
200
Q-5-21-0
ABORSI
121.625
125.273
127.706
130.138
201
Q-5-22-0
130.032
133.933
136.534
139.134
202
Q-5-23-0
159.194
163.969
167.153
170.337
203
Q-5-24-0
108.727
111.989
114.163
116.338
204
Q-5-25-0
169.557
174.644
178.035
181.426
205
Q-5-26-0
BRONKIAL AKUT
550.563
567.079
578.091
589.102
206
Q-5-27-0
170.793
175.917
179.333
182.749
207
Q-5-28-0
138.594
142.752
145.524
148.296
208
Q-5-29-0

JANTUNG LAIN-LAIN
392.384
404.155
412.003
419.850
209
Q-5-30-0
454.730
468.372
477.467
486.561
210
Q-5-31-0
FRAKTUR
162.230
167.096
170.341
173.586
211
Q-5-32-0
SALURAN KEMIH AKUT
187.898
193.535
197.293
201.051
212
Q-5-33-0
HEMATOLOGI AKUT
196.729
202.631
206.565
210.500
213
Q-5-34-0
INFEKSI VIRUS HIV
279.467
287.851
293.441
299.030
214
Q-5-35-0
INFEKSI AKUT
316.908
326.416
332.754
339.092
215
Q-5-36-0
369.060
380.132
387.513
394.894
216
Q-5-37-0

SHOCK
188.240
193.887
197.652
201.416
217
Q-5-38-0
PARU AKUT
575.859
593.134
604.652
616.169
218
Q-5-39-0
160.637
165.456
168.668
171.881
219
Q-5-40-0
157.610
162.339
165.491
168.643
220
Q-5-41-0
218.189
224.735
229.098
233.462
221
Q-5-42-0
171.069
176.201
179.622
183.044
222
Q-5-43-0
246.349
253.739
258.666
263.593
223
Q-5-44-0
201.055
207.087
211.108
215.129
224
T-2-10-0

TERAPI DETOKSIKASI
104.284
107.412
109.498
111.584
225
U-2-10-0
1.391.785
1.433.539
1.461.375
1.489.210
226
U-2-11-0

LEHER
1.654.292
1.703.920
1.737.006
1.770.092
227
U-2-12-0
182.015
187.476
191.116
194.756
228
U-2-13-0
238.627
245.785
250.558
255.330
- 207 Kode
INA-CBG
Deskripsi (INA-CBG)
229
U-2-14-0
443.260
456.558
465.423
474.288
230
U-2-15-0
251.851
259.406
264.443
269.480
293.367
302.168
308.035
313.902
566.808
583.812
595.148
606.484
742.701
764.982
779.836
794.690
No

(RHINOPLASTY)
Regional 1
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
231
U-2-21-0
232
U-2-22-0
233
U-2-23-0
234
U-2-24-0
625.936
644.714
657.233
669.751
235
U-2-25-0
238.627
245.785
250.558
255.330
236
U-2-31-0
191.760
197.513
201.348
205.183
237
U-2-32-0
238.627
245.785
250.558
255.330
238
U-3-10-0
228.140
234.984
239.546
244.109
239
U-3-11-0
242.213
249.479
254.324
259.168
240
U-3-12-0
107.106
110.319
112.462
114.604
241
U-3-13-0
235.428
242.491
247.199
251.908
242
U-3-14-0
216.310
222.799
227.125
231.451
243
U-3-15-0
188.641
194.301
198.073
201.846
244
U-3-16-0
PROSEDUR PADA GIGI
212.753
219.136
223.391
227.646
245
V-2-10-0

PROSTAT
2.075.654
2.137.923
2.179.436
2.220.949
246
V-2-11-0
234.081
241.103
245.785
250.467
746.986
769.395
784.335
799.275
329.860
339.756
346.353
352.950
329.860
339.756
346.353
352.950

RONGGA HIDUNG
TENGGOROKAN
PROSEDUR PADA PENIS

SKROTUM
SKROTUM
TRANSURETHRAL
247
V-2-12-0
248
V-2-13-0
249
V-2-14-0
250
V-2-15-0
SIRKUMSISI/SUNAT
180.623
186.042
189.654
193.267
251
V-3-10-0
376.702
388.003
395.537
403.071
252
V-3-11-0
796.919
820.827
836.765
852.704
253
V-3-12-0
460.083
473.885
483.087
492.288
254
W-2-10-0
168.470
173.524
176.893
180.262
255
W-2-11-0
430.545
443.462
452.073
460.684
256
W-2-12-0
796.919
820.827
836.765
852.704
257
W-2-13-0
127.812
131.646
134.202
136.758
258
W-2-21-0
1.602.020
1.650.081
1.682.121
1.714.162
259
W-2-22-0
168.470
173.524
176.893
180.262
260
W-2-23-0
562.191
579.057
590.301
601.545

PROSEDUR ABORSI
RAHIM & LEHER RAHIM
TERHALANG/TERGANGGU
TERHALANG/TERGANGGU
PANGGUL TERBUKA
PANGGUL TERBUKA
- 208 No
Kode
INA-CBG
261
W-2-31-0
262
W-2-32-0
263
W-2-33-0
264
Deskripsi (INA-CBG)
JALAN LAHIR
Regional 1
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
1.845.502
1.900.867
1.937.777
1.974.688
1.294.335
1.333.165
1.359.051
1.384.938
550.109
566.613
577.615
588.617
W-2-34-0
187.102
192.715
196.457
200.199
265
W-3-10-0
454.730
468.372
477.466
486.561
266
W-3-11-0
363.498
374.403
381.673
388.943
267
W-3-12-0
168.470
173.524
176.893
180.262
268
Z-3-10-0
1.907.300
1.964.519
2.002.665
2.040.811
269
Z-3-11-0

EMPEDU
1.457.785
1.501.518
1.530.674
1.559.830
270
Z-3-12-0
243.415
250.717
255.586
260.454
271
Z-3-13-0

LAIN-LAIN
1.485.384
1.529.945
1.559.653
1.589.361
272
Z-3-14-0
DIAGNOSTIK TIDUR
293.706
302.518
308.392
314.266
273
Z-3-15-0
191.760
197.513
201.348
205.183
274
Z-3-16-0

(MRI)
615.491
633.956
646.265
658.575
275
Z-3-17-0
PENGOBATAN NUKLIR
258.396
266.148
271.316
276.484
276
Z-3-18-0
CT-SCAN KEPALA
248.960
256.429
261.408
266.387
277
Z-3-19-0
CT SCAN LAIN-LAIN
259.119
266.892
272.075
277.257
278
Z-3-20-0
176.233
181.520
185.045
188.569
279
Z-3-21-0
168.470
173.524
176.893
180.262
280
Z-3-22-0
189.934
195.632
199.431
203.230
281
Z-3-23-0
197.833
203.768
207.725
211.681
282
Z-3-24-0
388.703
400.364
408.138
415.912
283
Z-3-25-0
173.128
178.321
181.784
185.247
284
Z-3-26-0
195.668
201.538
205.452
209.365
285
Z-3-27-0
PERAWATAN LUKA
186.810
192.415
196.151
199.887
286
Z-3-28-0
IMAGING PAYUDARA
191.760
197.513
201.348
205.183
287
Z-3-29-0
IMAGING LAIN-LAIN
552.686
569.267
580.321
591.375
288
Z-3-30-0
FOTOTERAPI
93.273
96.071
97.937
99.802
- 209 II.
TARIF INA-CBG RUMAH SAKIT UMUM DAN KHUSUS KELAS B

PENDIDIKAN TAHUN 2012
A. RUMAH SAKIT UMUM KELAS B PENDIDIKAN
1. RawatInap
No
Kode
INA-CBG
A-4-10-i
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
SEPTIKEMIA RINGAN
1.849.284
1.865.927
1.877.023
1.888.119
A-4-10-ii
SEPTIKEMIA SEDANG
3.160.592
3.189.037
3.208.001
3.226.964
A-4-10-iii
SEPTIKEMIA BERAT
4.524.760
4.565.483
4.592.631
4.619.780
A-4-11-i
4.962.144
5.006.803
5.036.576
5.066.349
A-4-11-ii
7.665.939
7.734.933
7.780.928
7.826.924
A-4-11-iii
15.402.078
15.540.697
15.633.109
15.725.522
A-4-12-i
DEMAM RINGAN
1.777.468
1.793.465
1.804.130
1.814.795
A-4-12-ii
DEMAM SEDANG
2.791.923
2.817.050
2.833.802
2.850.553
A-4-12-iii
DEMAM BERAT
3.195.151
3.223.907
3.243.078
3.262.249
10
A-4-13-i
2.221.835
2.241.831
2.255.162
2.268.493
11
A-4-13-ii
2.666.202
2.690.197
2.706.195
2.722.192
12
A-4-13-iii
3.240.453
3.269.617
3.289.060
3.308.502
1.777.468
1.793.465
1.804.130
1.814.795
2.776.944
2.801.937
2.818.598
2.835.260
3.098.989
3.126.880
3.145.473
3.164.067

LAIN-LAIN RINGAN
LAIN-LAIN SEDANG
LAIN-LAIN BERAT
13
A-4-14-i
14
A-4-14-ii
15
A-4-14-iii
16
A-4-15-i
INFEKSI HIV RINGAN
2.666.202
2.690.197
2.706.195
2.722.192
17
A-4-15-ii
INFEKSI HIV SEDANG
3.999.302
4.035.296
4.059.292
4.083.288
18
A-4-15-iii
INFEKSI HIV BERAT
6.091.222
6.146.043
6.182.591
6.219.138
19
B-1-01-i
29.559.000
29.825.031
30.002.385
30.179.740
20
B-1-01-ii
32.611.480
32.904.984
33.100.652
33.296.321
21
B-1-01-iii
57.207.247
57.722.112
58.065.356
58.408.599
22
B-1-10-i
3.832.224
3.866.714
3.889.707
3.912.701
23
B-1-10-ii
9.766.353
9.854.250
9.912.848
9.971.446
24
B-1-10-iii
18.616.547
18.784.096
18.895.795
19.007.495
2.869.056
2.894.878
2.912.092
2.929.307
7.201.602
7.266.417
7.309.626
7.352.836
9.029.022
9.110.283
9.164.457
9.218.631
6.119.801
6.174.879
6.211.598
6.248.317
25
B-1-11-i
26
B-1-11-ii
27
B-1-11-iii
28
B-1-12-i

(RINGAN)
(SEDANG)
(BERAT)
LAPAROSKOPIK RINGAN
- 210 No
Kode
INA-CBG
29
B-1-12-ii
30
B-1-12-iii
31
B-1-13-i
32
B-1-13-ii
33
B-1-13-iii
34
B-1-14-i
35
B-1-14-ii
36
B-1-14-iii
37
B-4-10-i
38
B-4-10-ii
39
B-4-10-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
13.116.230
13.234.276
13.312.973
13.391.671
15.962.946
16.106.613
16.202.390
16.298.168
4.010.169
4.046.261
4.070.322
4.094.383
6.531.984
6.590.772
6.629.963
6.669.155
9.629.977
9.716.647
9.774.426
9.832.206
5.445.528
5.494.537
5.527.211
5.559.884
6.056.526
6.111.034
6.147.374
6.183.713
9.474.714
9.559.987
9.616.835
9.673.683
1.523.576
1.537.288
1.546.429
1.555.571
2.221.835
2.241.831
2.255.162
2.268.493
3.720.079
3.753.560
3.775.880
3.798.201
3.678.483
3.711.589
3.733.660
3.755.731
5.592.213
5.642.543
5.676.096
5.709.649
6.023.007
6.077.214
6.113.352
6.149.490
3.227.617
3.256.665
3.276.031
3.295.397
4.575.966
4.617.150
4.644.606
4.672.062
8.696.517
8.774.786
8.826.965
8.879.144
2.666.202
2.690.197
2.706.195
2.722.192
3.160.190
3.188.632
3.207.593
3.226.554
5.618.040
5.668.603
5.702.311
5.736.019
2.795.105
2.820.261
2.837.032
2.853.803
3.140.928
3.169.196
3.188.042
3.206.887
4.149.811
4.187.160
4.212.058
4.236.957

LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT
LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT

PANCREAS RINGAN
PANCREAS SEDANG
PANCREAS BERAT
(RINGAN)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT
40
B-4-11-i
41
B-4-11-ii
42
B-4-11-iii
43
B-4-12-i
44
B-4-12-ii
45
B-4-12-iii
46
B-4-13-i
47
B-4-13-ii
48
B-4-13-iii
49
B-4-14-i
50
B-4-14-ii
51
B-4-14-iii
52
C-4-10-i
2.843.339
2.868.929
2.885.989
2.903.049
53
C-4-10-ii
5.524.309
5.574.027
5.607.173
5.640.319
54
C-4-10-iii
LEUKEMIA AKUT BERAT
8.442.971
8.518.958
8.569.616
8.620.274
55
C-4-11-i
2.860.389
2.886.132
2.903.295
2.920.457
56
C-4-11-ii
3.554.935
3.586.930
3.608.259
3.629.589
57
C-4-11-iii
6.618.769
6.678.337
6.718.050
6.757.763
58
C-4-12-i
RADIOTERAPI RINGAN
1.777.468
1.793.465
1.804.130
1.814.795
59
C-4-12-ii
RADIOTERAPI SEDANG
5.359.475
5.407.710
5.439.867
5.472.023
60
C-4-12-iii
RADIOTERAPI BERAT
10.880.807
10.978.734
11.044.019
11.109.304
- 211 No
Kode
INA-CBG
61
C-4-13-i
62
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
KEMOTERAPI RINGAN
1.777.468
1.793.465
1.804.130
1.814.795
C-4-13-ii
KEMOTERAPI SEDANG
3.554.935
3.586.930
3.608.259
3.629.589
63
C-4-13-iii
KEMOTERAPI BERAT
4.651.370
4.693.232
4.721.140
4.749.049
64
C-4-14-i
2.524.171
2.546.888
2.562.033
2.577.178
65
C-4-14-ii
3.688.480
3.721.676
3.743.807
3.765.938
66
C-4-14-iii
5.622.981
5.673.588
5.707.326
5.741.063
67
D-1-10-i
18.914.364
19.084.593
19.198.080
19.311.566
68
D-1-10-ii
28.808.028
29.067.300
29.240.148
29.412.996
69
D-1-10-iii
39.042.749
39.394.134
39.628.390
39.862.647
70
D-1-11-i
4.257.530
4.295.848
4.321.393
4.346.938
71
D-1-11-ii
11.104.420
11.204.360
11.270.986
11.337.613
72
D-1-11-iii
15.277.961
15.415.462
15.507.130
15.598.798
73
D-1-20-i
4.788.808
4.831.907
4.860.640
4.889.373
74
D-1-20-ii
10.774.818
10.871.792
10.936.441
11.001.089
75
D-1-20-iii
20.951.036
21.139.595
21.265.301
21.391.007
76
D-4-10-i
1.707.367
1.722.733
1.732.977
1.743.222
77
D-4-10-ii
3.447.495
3.478.522
3.499.207
3.519.892
78
D-4-10-iii
4.443.669
4.483.662
4.510.324
4.536.986
79
D-4-11-i
2.221.835
2.241.831
2.255.162
2.268.493
80
D-4-11-ii
4.096.459
4.133.328
4.157.906
4.182.485
81
D-4-11-iii
6.205.566
6.261.416
6.298.649
6.335.883
82
D-4-12-i
2.279.178
2.299.691
2.313.366
2.327.041
83
D-4-12-ii
3.161.444
3.189.897
3.208.866
3.227.835
84
D-4-12-iii
4.854.400
4.898.089
4.927.216
4.956.342
85
D-4-13-i
1.777.468
1.793.465
1.804.130
1.814.795
86
D-4-13-ii
2.666.202
2.690.197
2.706.195
2.722.192
87
D-4-13-iii
3.110.568
3.138.564
3.157.227
3.175.890
88
D-4-14-i
2.221.835
2.241.831
2.255.162
2.268.493
89
D-4-14-ii
5.000.186
5.045.188
5.075.189
5.105.190
90
D-4-14-iii
5.964.530
6.018.211
6.053.998
6.089.786
91
E-1-01-i
4.666.116
4.708.111
4.736.108
4.764.105
92
E-1-01-ii
6.112.168
6.167.178
6.203.851
6.240.524
93
E-1-01-iii
12.649.950
12.763.800
12.839.700
12.915.599

RINGAN
SEDANG
BERAT
TULANG RINGAN
TULANG SEDANG
TULANG BERAT


RINGAN
SEDANG
BERAT
- 212 No
Kode
INA-CBG
94
E-1-10-i
95
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.341.505
4.380.578
4.406.627
4.432.676
E-1-10-ii
5.269.567
5.316.994
5.348.611
5.380.228
96
E-1-10-iii
11.106.697
11.206.657
11.273.297
11.339.938
97
E-1-20-i
5.505.836
5.555.388
5.588.423
5.621.458
98
E-1-20-ii
7.374.177
7.440.545
7.484.790
7.529.035
99
E-1-20-iii
16.339.093
16.486.145
16.584.180
16.682.214
100
E-4-10-i
2.259.199
2.279.531
2.293.087
2.306.642
101
E-4-10-ii
3.460.527
3.491.672
3.512.435
3.533.198
102
E-4-10-iii
6.040.118
6.094.479
6.130.720
6.166.961
103
E-4-11-i
2.076.031
2.094.716
2.107.172
2.119.628
104
E-4-11-ii
3.927.495
3.962.842
3.986.407
4.009.972
105
E-4-11-iii
6.476.620
6.534.909
6.573.769
6.612.629
106
E-4-12-i
2.444.018
2.466.014
2.480.678
2.495.342
107
E-4-12-ii
3.999.302
4.035.296
4.059.292
4.083.288
108
E-4-12-iii
6.425.355
6.483.183
6.521.735
6.560.287
2.616.513
2.640.062
2.655.761
2.671.460
4.492.571
4.533.004
4.559.960
4.586.915
7.773.282
7.843.242
7.889.882
7.936.521

RINGAN
SEDANG
BERAT

RINGAN
SEDANG
BERAT
109
E-4-13-i
110
E-4-13-ii
111
E-4-13-iii
112
F-4-10-i
SCHIZOFRENIA RINGAN
3.199.182
3.227.975
3.247.170
3.266.365
113
F-4-10-ii
SCHIZOFRENIA SEDANG
3.552.794
3.584.770
3.606.086
3.627.403
114
F-4-10-iii
SCHIZOFRENIA BERAT
5.259.991
5.307.330
5.338.890
5.370.450
115
F-4-11-i
2.948.871
2.975.411
2.993.104
3.010.797
116
F-4-11-ii
3.435.715
3.466.636
3.487.250
3.507.865
117
F-4-11-iii
DEPRESI MAYOR BERAT
4.405.842
4.445.494
4.471.929
4.498.364
1.440.036
1.452.997
1.461.637
1.470.277
1.903.479
1.920.610
1.932.031
1.943.452
4.129.278
4.166.441
4.191.217
4.215.993

IMPULSE RINGAN
IMPULSE SEDANG
IMPULSE BERAT
118
F-4-12-i
119
F-4-12-ii
120
F-4-12-iii
121
F-4-13-i
2.383.136
2.404.584
2.418.883
2.433.182
122
F-4-13-ii
3.155.884
3.184.287
3.203.222
3.222.158
123
F-4-13-iii
4.069.110
4.105.732
4.130.146
4.154.561
124
F-4-14-i
DEPRESI RINGAN
1.668.195
1.683.209
1.693.218
1.703.227
125
F-4-14-ii
DEPRESI SEDANG
2.139.798
2.159.057
2.171.895
2.184.734
126
F-4-14-iii
DEPRESI BERAT
2.879.194
2.905.107
2.922.382
2.939.657
- 213 No
Kode
INA-CBG
127
F-4-15-i
128
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.983.389
2.001.239
2.013.140
2.025.040
F-4-15-ii
2.792.201
2.817.331
2.834.084
2.850.837
129
F-4-15-iii
3.511.551
3.543.155
3.564.224
3.585.294
130
F-4-16-i
4.271.832
4.310.278
4.335.909
4.361.540
131
F-4-16-ii
4.965.897
5.010.590
5.040.386
5.070.181
132
F-4-16-iii
6.628.644
6.688.302
6.728.074
6.767.846
133
F-4-17-i
900.636
908.741
914.145
919.549
134
F-4-17-ii
2.639.677
2.663.434
2.679.273
2.695.111
135
F-4-17-iii
2.816.342
2.841.689
2.858.587
2.875.485
136
F-4-18-i
3.702.680
3.736.004
3.758.220
3.780.436
137
F-4-18-ii
4.073.993
4.110.659
4.135.103
4.159.547
138
F-4-18-iii
6.280.416
6.336.940
6.374.622
6.412.305
139
F-4-19-i
2.839.606
2.865.162
2.882.200
2.899.238
140
F-4-19-ii
3.636.189
3.668.914
3.690.731
3.712.549
141
F-4-19-iii
4.527.103
4.567.847
4.595.010
4.622.173
142
G-1-01-i
8.243.490
8.317.681
8.367.142
8.416.603
143
G-1-01-ii
13.953.100
14.078.678
14.162.396
14.246.115
144
G-1-01-iii
27.011.643
27.254.747
27.416.817
27.578.887
145
G-1-10-i
4.505.284
4.545.832
4.572.864
4.599.895
146
G-1-10-ii
6.360.341
6.417.584
6.455.747
6.493.909
147
G-1-10-iii
7.538.363
7.606.208
7.651.439
7.696.669
148
G-1-11-i
5.196.980
5.243.753
5.274.935
5.306.117
149
G-1-11-ii
10.672.390
10.768.441
10.832.476
10.896.510
150
G-1-11-iii
22.347.014
22.548.137
22.682.219
22.816.301
151
G-1-12-i
4.041.719
4.078.095
4.102.345
4.126.595
152
G-1-12-ii
9.253.114
9.336.392
9.391.910
9.447.429
153
G-1-12-iii
15.931.210
16.074.591
16.170.179
16.265.766
154
G-1-13-i
973.332
982.092
987.932
993.772
155
G-1-13-ii
2.614.262
2.637.791
2.653.476
2.669.162
156
G-1-13-iii
5.898.877
5.951.967
5.987.360
6.022.754
157
G-1-20-i
5.092.910
5.138.746
5.169.304
5.199.861
158
G-1-20-ii
6.880.688
6.942.615
6.983.899
7.025.183
159
G-1-20-iii
16.846.556
16.998.175
17.099.254
17.200.334

RINGAN
SEDANG
BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

RINGAN
SEDANG
BERAT
- 214 No
Kode
INA-CBG
160
G-1-30-i
161
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
6.495.548
6.554.008
6.592.981
6.631.955
G-1-30-ii
16.954.004
17.106.590
17.208.314
17.310.038
162
G-1-30-iii
21.825.042
22.021.468
22.152.418
22.283.368
163
G-4-10-i
2.666.202
2.690.197
2.706.195
2.722.192
164
G-4-10-ii
3.110.568
3.138.564
3.157.227
3.175.890
165
G-4-10-iii
5.204.164
5.251.001
5.282.226
5.313.451
166
G-4-11-i
4.817.533
4.860.891
4.889.796
4.918.701
167
G-4-11-ii
5.588.338
5.638.634
5.672.164
5.705.694
168
G-4-11-iii
8.189.806
8.263.515
8.312.653
8.361.792
169
G-4-12-i
3.603.091
3.635.519
3.657.137
3.678.756
170
G-4-12-ii
4.539.894
4.580.753
4.607.993
4.635.232
171
G-4-12-iii
6.593.656
6.652.999
6.692.561
6.732.123
172
G-4-13-i
2.004.736
2.022.778
2.034.807
2.046.835
173
G-4-13-ii
3.110.568
3.138.564
3.157.227
3.175.890
174
G-4-13-iii
3.677.134
3.710.228
3.732.291
3.754.353
175
G-4-14-i
3.666.363
3.699.360
3.721.358
3.743.356
176
G-4-14-ii
6.032.404
6.086.695
6.122.890
6.159.084
177
G-4-14-iii
7.552.707
7.620.681
7.665.997
7.711.314
178
G-4-15-i
2.666.202
2.690.197
2.706.195
2.722.192
179
G-4-15-ii
3.380.143
3.410.565
3.430.845
3.451.126
180
G-4-15-iii
5.116.634
5.162.683
5.193.383
5.224.083
181
G-4-16-i
2.221.835
2.241.831
2.255.162
2.268.493
182
G-4-16-ii
3.322.774
3.352.679
3.372.615
3.392.552
183
G-4-16-iii
6.030.241
6.084.513
6.120.694
6.156.876
184
G-4-17-i
3.477.270
3.508.565
3.529.429
3.550.293
185
G-4-17-ii
4.315.445
4.354.284
4.380.177
4.406.069
186
G-4-17-iii
7.232.721
7.297.816
7.341.212
7.384.609
187
G-4-18-i
2.666.202
2.690.197
2.706.195
2.722.192
188
G-4-18-ii
4.186.551
4.224.230
4.249.349
4.274.468
189
G-4-18-iii
4.435.224
4.475.141
4.501.753
4.528.364

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
DEGENERATIF RINGAN
DEGENERATIF SEDANG
DEGENERATIF BERAT
RINGAN
SEDANG
BERAT
TRAUMATIK RINGAN
TRAUMATIK SEDANG
TRAUMATIK BERAT
DENGAN INFARK BERAT
TANPA INFARK RINGAN
TANPA INFARK SEDANG
TANPA INFARK BERAT

PERIFER RINGAN
PERIFER SEDANG
PERIFER BERAT
PERSARAFAN RINGAN
PERSARAFAN SEDANG
PERSARAFAN BERAT
- 215 No
Kode
INA-CBG
190
G-4-19-i
191
G-4-19-ii
192
G-4-19-iii
193
G-4-20-i
194
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.431.904
2.453.791
2.468.382
2.482.974
4.502.847
4.543.372
4.570.389
4.597.406
6.716.818
6.777.269
6.817.570
6.857.871
1.555.284
1.569.282
1.578.613
1.587.945
G-4-20-ii
2.208.505
2.228.382
2.241.633
2.254.884
195
G-4-20-iii
3.766.019
3.799.913
3.822.509
3.845.105
196
G-4-21-i
1.973.668
1.991.431
2.003.273
2.015.115
197
G-4-21-ii
4.087.664
4.124.453
4.148.979
4.173.505
198
G-4-21-iii
4.815.751
4.859.092
4.887.987
4.916.881
199
G-4-22-i
1.777.468
1.793.465
1.804.130
1.814.795
200
G-4-22-ii
2.221.835
2.241.831
2.255.162
2.268.493
201
G-4-22-iii
2.549.025
2.571.966
2.587.260
2.602.555
202
G-4-23-i
1.777.468
1.793.465
1.804.130
1.814.795
203
G-4-23-ii
2.221.835
2.241.831
2.255.162
2.268.493
204
G-4-23-iii
3.175.955
3.204.539
3.223.595
3.242.650
205
G-4-24-i
1.777.468
1.793.465
1.804.130
1.814.795
206
G-4-24-ii
2.221.835
2.241.831
2.255.162
2.268.493
207
G-4-24-iii
TRAUMA KEPALA BERAT
4.668.945
4.710.965
4.738.979
4.766.993
208
G-4-25-i
GEGAR OTAK RINGAN
1.777.468
1.793.465
1.804.130
1.814.795
209
G-4-25-ii
GEGAR OTAK SEDANG
2.221.835
2.241.831
2.255.162
2.268.493
210
G-4-25-iii
GEGAR OTAK BERAT
2.774.383
2.799.352
2.815.998
2.832.645
211
G-4-26-i
2.933.472
2.959.873
2.977.474
2.995.075
212
G-4-26-ii
3.326.655
3.356.595
3.376.555
3.396.515
213
G-4-26-iii
5.937.640
5.991.079
6.026.705
6.062.330
214
H-1-20-i
2.797.973
2.823.155
2.839.942
2.856.730
215
H-1-20-ii
5.102.420
5.148.342
5.178.956
5.209.571
216
H-1-20-iii
6.938.973
7.001.423
7.043.057
7.084.691
217
H-1-30-i
2.739.482
2.764.137
2.780.574
2.797.011
218
H-1-30-ii
3.123.009
3.151.116
3.169.854
3.188.593
219
H-1-30-iii
5.210.628
5.257.524
5.288.788
5.320.051
220
H-4-10-i
2.666.202
2.690.197
2.706.195
2.722.192
221
H-4-10-ii
4.443.669
4.483.662
4.510.324
4.536.986
222
H-4-10-iii
7.244.493
7.309.694
7.353.161
7.396.628

SEDANG

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)

RINGAN
SEDANG
- 216 No
Kode
INA-CBG
223
H-4-11-i
224
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.988.093
2.005.986
2.017.914
2.029.843
H-4-11-ii
2.194.473
2.214.223
2.227.390
2.240.557
225
H-4-11-iii
2.900.463
2.926.567
2.943.970
2.961.372
226
H-4-12-i
2.758.399
2.783.225
2.799.775
2.816.326
227
H-4-12-ii
3.736.432
3.770.060
3.792.479
3.814.898
228
H-4-12-iii
6.233.983
6.290.089
6.327.492
6.364.896
38.346.736
38.691.856
38.921.937
39.152.017
39.190.564
39.543.279
39.778.422
40.013.566
61.861.553
62.418.307
62.789.477
63.160.646
21.274.548
21.466.019
21.593.666
21.721.314
27.444.167
27.691.165
27.855.830
28.020.495
33.826.531
34.130.970
34.333.929
34.536.889
13.101.624
13.219.538
13.298.148
13.376.758
17.958.030
18.119.653
18.227.401
18.335.149
26.338.445
26.575.491
26.733.521
26.891.552
17.504.156
17.661.694
17.766.718
17.871.743
22.484.399
22.686.759
22.821.665
22.956.572
47.932.071
48.363.460
48.651.052
48.938.645
28.157.490
28.410.908
28.579.852
28.748.797
33.788.988
34.093.089
34.295.823
34.498.557
46.493.434
46.911.875
47.190.836
47.469.797

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
KATETERISASI RINGAN
KATETERISASI SEDANG
KATETERISASI BERAT
RINGAN
SEDANG
BERAT
229
I-1-01-i
230
I-1-01-ii
231
I-1-01-iii
232
I-1-02-i
233
I-1-02-ii
234
I-1-02-iii
235
I-1-03-i
236
I-1-03-ii
237
I-1-03-iii
238
I-1-04-i
239
I-1-04-ii
240
I-1-04-iii
241
I-1-05-i
242
I-1-05-ii
243
I-1-05-iii
244
I-1-06-i
14.535.492
14.666.312
14.753.525
14.840.738
245
I-1-06-ii
21.937.508
22.134.946
22.266.571
22.398.196
246
I-1-06-iii
25.788.128
26.020.221
26.174.949
26.329.678
247
I-1-07-i
19.115.273
19.287.310
19.402.002
19.516.694
248
I-1-07-ii
23.582.572
23.794.816
23.936.311
24.077.806
249
I-1-07-iii
25.728.433
25.959.989
26.114.360
26.268.730
250
I-1-11-i
3.636.191
3.668.917
3.690.734
3.712.551
251
I-1-11-ii
4.043.081
4.079.469
4.103.727
4.127.986
252
I-1-11-iii
5.380.108
5.428.529
5.460.810
5.493.091

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
RINGAN
SEDANG
BERAT
- 217 No
Kode
INA-CBG
253
I-1-12-i
254
I-1-12-ii
255
I-1-12-iii
256
I-1-13-i
257
I-1-13-ii
258
I-1-13-iii
259
I-1-14-i
260
I-1-14-ii
261
I-1-14-iii
262
I-1-15-i
263
I-1-15-ii
264
I-1-15-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
10.176.217
10.267.803
10.328.861
10.389.918
14.119.976
14.247.056
14.331.776
14.416.496
19.694.034
19.871.280
19.989.445
20.107.609
5.714.211
5.765.639
5.799.924
5.834.210
6.941.100
7.003.570
7.045.217
7.086.863
13.903.315
14.028.445
14.111.865
14.195.285
21.900.270
22.097.373
22.228.774
22.360.176
27.218.907
27.463.877
27.627.191
27.790.504
35.666.154
35.987.150
36.201.146
36.415.143
7.039.483
7.102.838
7.145.075
7.187.312
12.570.621
12.683.757
12.759.181
12.834.604
65.030.190
65.615.462
66.005.643
66.395.824
9.385.830
9.470.303
9.526.617
9.582.932
24.403.158
24.622.787
24.769.205
24.915.624
28.148.444
28.401.780
28.570.671
28.739.561
3.296.471
3.326.139
3.345.918
3.365.696
6.828.186
6.889.639
6.930.608
6.971.577
39.585.666
39.941.937
40.179.451
40.416.965
5.300.508
5.348.213
5.380.016
5.411.819
8.801.942
8.881.160
8.933.971
8.986.783
17.823.612
17.984.025
18.090.966
18.197.908
10.648.273
10.744.107
10.807.997
10.871.887
22.150.559
22.349.914
22.482.817
22.615.721
34.325.321
34.634.249
34.840.201
35.046.153
15.681.779
15.822.915
15.917.005
16.011.096
21.248.999
21.440.240
21.567.734
21.695.228
26.281.257
26.517.789
26.675.476
26.833.164

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

DARAH VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
265
I-1-16-i
266
I-1-16-ii
267
I-1-16-iii
268
I-1-17-i
269
I-1-17-ii
270
I-1-17-iii
271
I-1-20-i
272
I-1-20-ii
273
I-1-20-iii
274
I-1-30-i
275
I-1-30-ii
276
I-1-30-iii
277
I-1-40-i
278
I-1-40-ii
279
I-1-40-iii
280
I-4-10-i
4.560.717
4.601.763
4.629.128
4.656.492
281
I-4-10-ii
7.201.454
7.266.267
7.309.476
7.352.684
- 218 No
Kode
INA-CBG
282
I-4-10-iii
283
I-4-11-i
284
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
10.388.725
10.482.224
10.544.556
10.606.889
5.407.818
5.456.488
5.488.935
5.521.382
I-4-11-ii
6.665.504
6.725.493
6.765.486
6.805.479
285
I-4-11-iii
10.814.762
10.912.095
10.976.984
11.041.872
286
I-4-12-i
4.736.686
4.779.316
4.807.736
4.836.157
287
I-4-12-ii
6.759.238
6.820.071
6.860.626
6.901.182
288
I-4-12-iii
8.199.906
8.273.705
8.322.905
8.372.104
289
I-4-13-i
4.254.846
4.293.140
4.318.669
4.344.198
290
I-4-13-ii
6.181.423
6.237.056
6.274.145
6.311.233
291
I-4-13-iii
11.553.540
11.657.522
11.726.843
11.796.164
292
I-4-14-i
2.646.121
2.669.936
2.685.813
2.701.690
293
I-4-14-ii
3.096.353
3.124.220
3.142.799
3.161.377
294
I-4-14-iii
4.798.317
4.841.502
4.870.292
4.899.082
3.554.935
3.586.930
3.608.259
3.629.589
5.573.202
5.623.360
5.656.800
5.690.239
6.352.109
6.409.278
6.447.390
6.485.503

VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT

295
I-4-15-i
296
I-4-15-ii
297
I-4-15-iii
298
I-4-16-i
2.666.202
2.690.197
2.706.195
2.722.192
299
I-4-16-ii
4.320.994
4.359.883
4.385.809
4.411.735
300
I-4-16-iii
5.443.686
5.492.679
5.525.341
5.558.003
301
I-4-17-i
HIPERTENSI RINGAN
2.613.200
2.636.719
2.652.398
2.668.077
302
I-4-17-ii
HIPERTENSI SEDANG
3.564.880
3.596.964
3.618.353
3.639.743
303
I-4-17-iii
HIPERTENSI BERAT
4.166.629
4.204.129
4.229.129
4.254.128
3.848.493
3.883.129
3.906.220
3.929.311
5.895.633
5.948.694
5.984.068
6.019.441
7.948.258
8.019.793
8.067.482
8.115.172
3.011.950
3.039.057
3.057.129
3.075.201
4.889.464
4.933.469
4.962.806
4.992.143
5.600.726
5.651.132
5.684.737
5.718.341

RINGAN
SEDANG
KONGENITAL BERAT
RINGAN
SEDANG
BERAT
304
I-4-18-i
305
I-4-18-ii
306
I-4-18-iii
307
I-4-19-i
308
I-4-19-ii
309
I-4-19-iii
310
I-4-20-i
3.655.428
3.688.327
3.710.259
3.732.192
311
I-4-20-ii
4.211.326
4.249.228
4.274.496
4.299.764
312
I-4-20-iii
5.589.130
5.639.433
5.672.967
5.706.502
313
I-4-21-i
4.861.127
4.904.878
4.934.044
4.963.211
314
I-4-21-ii
6.063.941
6.118.517
6.154.900
6.191.284
- 219 No
Kode
INA-CBG
315
I-4-21-iii
316
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
8.272.502
8.346.954
8.396.589
8.446.224
I-4-22-i
2.888.385
2.914.380
2.931.711
2.949.041
317
I-4-22-ii
3.328.284
3.358.239
3.378.208
3.398.178
318
I-4-22-iii
4.855.876
4.899.579
4.928.714
4.957.849
2.188.115
2.207.808
2.220.936
2.234.065
2.686.500
2.710.679
2.726.798
2.742.917
5.249.177
5.296.420
5.327.915
5.359.410
2.858.064
2.883.787
2.900.935
2.918.084
7.135.796
7.200.018
7.242.833
7.285.648
9.021.925
9.103.123
9.157.254
9.211.386
23.026.547
23.233.786
23.371.945
23.510.105
24.599.177
24.820.569
24.968.164
25.115.760
42.027.838
42.406.089
42.658.256
42.910.423
11.770.714
11.876.651
11.947.275
12.017.899
12.609.571
12.723.057
12.798.715
12.874.372
18.633.353
18.801.054
18.912.854
19.024.654
4.593.103
4.634.441
4.661.999
4.689.558
11.094.013
11.193.859
11.260.423
11.326.987
19.643.313
19.820.103
19.937.962
20.055.822
3.969.911
4.005.640
4.029.459
4.053.279
5.773.921
5.825.887
5.860.530
5.895.174
8.682.195
8.760.334
8.812.427
8.864.521
2.677.130
2.701.224
2.717.287
2.733.350
11.972.020
12.079.769
12.151.601
12.223.433
36.107.088
36.432.051
36.648.694
36.865.336

RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
319
I-4-23-i
320
I-4-23-ii
321
I-4-23-iii
322
I-4-24-i
323
I-4-24-ii
324
I-4-24-iii
325
J-1-01-i
326
J-1-01-ii
327
J-1-01-iii
328
J-1-02-i
329
J-1-02-ii
330
J-1-02-iii
331
J-1-10-i
332
J-1-10-ii
333
J-1-10-iii
334
J-1-20-i
335
J-1-20-ii
336
J-1-20-iii
337
J-1-30-i
338
J-1-30-ii
339
J-1-30-iii
340
J-4-10-i
2.821.362
2.846.754
2.863.683
2.880.611
341
J-4-10-ii
4.034.209
4.070.517
4.094.722
4.118.927
342
J-4-10-iii
6.103.156
6.158.084
6.194.703
6.231.322
343
J-4-11-i
1.949.249
1.966.792
1.978.488
1.990.183
344
J-4-11-ii
2.713.310
2.737.730
2.754.010
2.770.289
345
J-4-11-iii
3.888.242
3.923.237
3.946.566
3.969.895
- 220 No
Kode
INA-CBG
346
J-4-12-i
347
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
EMBOLI PARU RINGAN
2.721.961
2.746.458
2.762.790
2.779.122
J-4-12-ii
EMBOLI PARU SEDANG
3.524.846
3.556.570
3.577.719
3.598.868
348
J-4-12-iii
EMBOLI PARU BERAT
4.707.076
4.749.439
4.777.682
4.805.924
349
J-4-13-i
4.591.730
4.633.055
4.660.606
4.688.156
350
J-4-13-ii
6.749.843
6.810.591
6.851.091
6.891.590
351
J-4-13-iii
10.974.234
11.073.002
11.138.848
11.204.693
352
J-4-14-i
TUMOR PARU RINGAN
3.129.119
3.157.281
3.176.056
3.194.830
353
J-4-14-ii
TUMOR PARU SEDANG
5.241.702
5.288.878
5.320.328
5.351.778
354
J-4-14-iii
TUMOR PARU BERAT
6.232.118
6.288.207
6.325.599
6.362.992
2.739.424
2.764.079
2.780.516
2.796.952
3.857.272
3.891.988
3.915.131
3.938.275
4.847.157
4.890.781
4.919.864
4.948.947
2.221.835
2.241.831
2.255.162
2.268.493
3.220.436
3.249.419
3.268.742
3.288.065
5.611.138
5.661.638
5.695.305
5.728.972

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
355
J-4-15-i
356
J-4-15-ii
357
J-4-15-iii
358
J-4-16-i
359
J-4-16-ii
360
J-4-16-iii
361
J-4-17-i
2.242.750
2.262.934
2.276.391
2.289.847
362
J-4-17-ii
3.044.062
3.071.459
3.089.723
3.107.987
363
J-4-17-iii
4.901.658
4.945.773
4.975.183
5.004.593
364
J-4-18-i
1.777.468
1.793.465
1.804.130
1.814.795
365
J-4-18-ii
2.444.018
2.466.014
2.480.678
2.495.342
366
J-4-18-iii
2.573.401
2.596.562
2.612.002
2.627.443
367
J-4-19-i
3.110.568
3.138.564
3.157.227
3.175.890
368
J-4-19-ii
3.857.244
3.891.959
3.915.103
3.938.246
369
J-4-19-iii
5.569.223
5.619.346
5.652.761
5.686.177
370
J-4-20-i
3.137.344
3.165.580
3.184.404
3.203.228
371
J-4-20-ii
4.155.282
4.192.679
4.217.611
4.242.542
372
J-4-20-iii
8.573.792
8.650.956
8.702.399
8.753.842
1.777.468
1.793.465
1.804.130
1.814.795
4.385.337
4.424.805
4.451.117
4.477.429
6.254.925
6.311.220
6.348.749
6.386.279
4.788.808
4.831.907
4.860.640
4.889.373
7.318.876
7.384.746
7.428.659
7.472.572
8.571.664
8.648.809
8.700.239
8.751.669
373
J-4-21-i
374
J-4-21-ii
375
J-4-21-iii
376
K-1-10-i
377
K-1-10-ii
378
K-1-10-iii

USUS BESAR (RINGAN)
USUS BESAR (SEDANG)
USUS BESAR (BERAT)
- 221 No
Kode
INA-CBG
Deskripsi (INA-CBG)
379
K-1-11-i
380
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.509.360
4.549.944
4.577.000
4.604.056
K-1-11-ii
5.920.245
5.973.527
6.009.049
6.044.570
381
K-1-11-iii
15.024.417
15.159.636
15.249.783
15.339.929
382
K-1-12-i
2.425.690
2.447.522
2.462.076
2.476.630
383
K-1-12-ii
3.161.425
3.189.878
3.208.846
3.227.815
384
K-1-12-iii
6.288.739
6.345.337
6.383.070
6.420.802
385
K-1-13-i
2.755.252
2.780.049
2.796.581
2.813.112
386
K-1-13-ii
4.812.633
4.855.947
4.884.823
4.913.699
387
K-1-13-iii
5.146.938
5.193.260
5.224.142
5.255.024
388
K-1-14-i
4.452.650
4.492.724
4.519.440
4.546.156
389
K-1-14-ii
5.230.142
5.277.213
5.308.594
5.339.975
390
K-1-14-iii
12.878.126
12.994.029
13.071.297
13.148.566
391
K-1-20-i
8.639.447
8.717.202
8.769.039
8.820.875
392
K-1-20-ii
12.058.390
12.166.915
12.239.265
12.311.616
393
K-1-20-iii
25.757.290
25.989.105
26.143.649
26.298.193
394
K-1-30-i
5.686.914
5.738.096
5.772.218
5.806.339
395
K-1-30-ii
9.577.616
9.663.815
9.721.280
9.778.746
396
K-1-30-iii
16.334.896
16.481.910
16.579.919
16.677.929
397
K-1-40-i
5.713.192
5.764.610
5.798.889
5.833.169
398
K-1-40-ii
6.286.800
6.343.381
6.381.102
6.418.823
399
K-1-40-iii
10.426.052
10.519.887
10.582.443
10.644.999
400
K-1-50-i
4.357.787
4.397.007
4.423.154
4.449.300
401
K-1-50-ii
5.643.539
5.694.331
5.728.192
5.762.054
402
K-1-50-iii
PROSEDUR ANAL BERAT
8.012.325
8.084.436
8.132.510
8.180.584
403
K-4-10-i
3.300.710
3.330.416
3.350.221
3.370.025
404
K-4-10-ii
3.949.493
3.985.039
4.008.736
4.032.433
405
K-4-10-iii
14.934.084
15.068.491
15.158.096
15.247.700
406
K-4-11-i
1.777.468
1.793.465
1.804.130
1.814.795
407
K-4-11-ii
2.666.202
2.690.197
2.706.195
2.722.192
408
K-4-11-iii
4.845.449
4.889.058
4.918.131
4.947.203
409
K-4-12-i
1.777.468
1.793.465
1.804.130
1.814.795
410
K-4-12-ii
2.908.134
2.934.308
2.951.756
2.969.205
411
K-4-12-iii
6.979.315
7.042.129
7.084.005
7.125.881


RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
- 222 No
Kode
INA-CBG
412
K-4-13-i
413
K-4-13-ii
414
K-4-13-iii
415
K-4-14-i
416
K-4-14-ii
417
K-4-14-iii
418
K-4-15-i
419
K-4-15-ii
420
K-4-15-iii
421
K-4-16-i
422
K-4-16-ii
423
K-4-16-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.666.202
2.690.197
2.706.195
2.722.192
3.453.387
3.484.468
3.505.188
3.525.909
5.648.231
5.699.065
5.732.954
5.766.843
2.221.835
2.241.831
2.255.162
2.268.493
3.007.021
3.034.084
3.052.127
3.070.169
4.548.406
4.589.342
4.616.633
4.643.923
2.221.835
2.241.831
2.255.162
2.268.493
4.177.655
4.215.254
4.240.320
4.265.386
5.944.051
5.997.548
6.033.212
6.068.876
2.221.835
2.241.831
2.255.162
2.268.493
2.666.202
2.690.197
2.706.195
2.722.192
3.564.049
3.596.125
3.617.510
3.638.894
1.777.468
1.793.465
1.804.130
1.814.795
2.840.071
2.865.632
2.882.672
2.899.713
3.779.845
3.813.863
3.836.542
3.859.222
1.940.223
1.957.685
1.969.326
1.980.967
3.021.873
3.049.070
3.067.201
3.085.332
3.513.739
3.545.363
3.566.445
3.587.528
19.919.664
20.098.941
20.218.459
20.337.977
20.652.249
20.838.120
20.962.033
21.085.947
31.748.407
32.034.143
32.224.634
32.415.124
8.380.414
8.455.838
8.506.120
8.556.403
13.087.188
13.204.973
13.283.496
13.362.019
13.802.900
13.927.126
14.009.943
14.092.761
3.648.059
3.680.892
3.702.780
3.724.669
8.210.687
8.284.583
8.333.847
8.383.111
13.739.486
13.863.141
13.945.578
14.028.015

(RINGAN)
(SEDANG)
RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
424
K-4-17-i
425
K-4-17-ii
426
K-4-17-iii
427
K-4-18-i
428
K-4-18-ii
429
K-4-18-iii
430
L-1-20-i
431
L-1-20-ii
432
L-1-20-iii
433
L-1-30-i
434
L-1-30-ii
435
L-1-30-iii
436
L-1-40-i
437
L-1-40-ii
438
L-1-40-iii
439
L-1-50-i
5.986.010
6.039.884
6.075.800
6.111.716
440
L-1-50-ii
10.774.818
10.871.792
10.936.441
11.001.089
441
L-1-50-iii
13.028.280
13.145.534
13.223.704
13.301.874
442
L-4-10-i
2.666.202
2.690.197
2.706.195
2.722.192
- 223 No
Kode
INA-CBG
443
L-4-10-ii
444
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.348.231
3.378.365
3.398.455
3.418.544
L-4-10-iii
6.891.027
6.953.046
6.994.393
7.035.739
445
L-4-11-i
2.761.641
2.786.495
2.803.065
2.819.635
446
L-4-11-ii
3.783.399
3.817.450
3.840.150
3.862.851
447
L-4-11-iii
10.260.106
10.352.447
10.414.007
10.475.568
448
L-4-12-i
2.726.226
2.750.762
2.767.119
2.783.476
449
L-4-12-ii
4.284.088
4.322.645
4.348.350
4.374.054
450
L-4-12-iii
6.937.928
7.000.369
7.041.997
7.083.624
451
L-4-13-i
1.832.698
1.849.192
1.860.188
1.871.185
452
L-4-13-ii
2.113.209
2.132.228
2.144.907
2.157.586
453
L-4-13-iii
3.169.978
3.198.508
3.217.528
3.236.547
454
L-4-14-i
1.777.468
1.793.465
1.804.130
1.814.795
455
L-4-14-ii
2.666.202
2.690.197
2.706.195
2.722.192
456
L-4-14-iii
4.565.228
4.606.316
4.633.707
4.661.098
457
M-1-01-i
8.665.847
8.743.840
8.795.835
8.847.830
458
M-1-01-ii
9.672.488
9.759.540
9.817.575
9.875.610
459
M-1-01-iii
13.587.225
13.709.510
13.791.033
13.872.556
460
M-1-02-i
6.721.518
6.782.012
6.822.341
6.862.670
461
M-1-02-ii
11.035.455
11.134.774
11.200.987
11.267.200
462
M-1-02-iii
19.984.703
20.164.565
20.284.474
20.404.382
15.563.626
15.703.699
15.797.081
15.890.463
18.213.994
18.377.920
18.487.204
18.596.488
19.298.536
19.472.223
19.588.015
19.703.806
4.433.984
4.473.890
4.500.494
4.527.098
5.684.322
5.735.480
5.769.586
5.803.692
7.112.857
7.176.873
7.219.550
7.262.227
6.907.296
6.969.461
7.010.905
7.052.349
7.982.983
8.054.830
8.102.728
8.150.626
13.597.194
13.719.569
13.801.152
13.882.735
6.962.343
7.025.004
7.066.778
7.108.552
9.327.364
9.411.310
9.467.274
9.523.238
19.000.724
19.171.730
19.285.735
19.399.739
463
M-1-03-i
464
M-1-03-ii
465
M-1-03-iii
466
M-1-04-i
467
M-1-04-ii
468
M-1-04-iii
469
M-1-05-i
470
M-1-05-ii
471
M-1-05-iii
472
M-1-07-i
473
M-1-07-ii
474
M-1-07-iii


- 224 No
Kode
INA-CBG
475
M-1-10-i
476
M-1-10-ii
477
M-1-10-iii
478
M-1-20-i
479
M-1-20-ii
480
M-1-20-iii
481
M-1-30-i
482
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.765.283
4.808.171
4.836.762
4.865.354
17.700.868
17.860.176
17.966.381
18.072.586
21.308.347
21.500.122
21.627.972
21.755.822
4.714.096
4.756.523
4.784.808
4.813.092
5.679.429
5.730.543
5.764.620
5.798.697
13.079.611
13.197.327
13.275.805
13.354.283
2.819.734
2.845.112
2.862.030
2.878.949
M-1-30-ii
5.826.288
5.878.725
5.913.683
5.948.640
483
M-1-30-iii
PROSEDUR KAKI BERAT
8.691.594
8.769.818
8.821.968
8.874.117
484
M-1-40-i
2.784.489
2.809.549
2.826.256
2.842.963
485
M-1-40-ii
4.788.808
4.831.907
4.860.640
4.889.373
486
M-1-40-iii
8.380.414
8.455.838
8.506.120
8.556.403
487
M-1-50-i
3.773.304
3.807.263
3.829.903
3.852.543
488
M-1-50-ii
7.595.749
7.664.111
7.709.685
7.755.260
489
M-1-50-iii
9.577.616
9.663.815
9.721.280
9.778.746
490
M-1-60-i
2.847.654
2.873.282
2.890.368
2.907.454
491
M-1-60-ii
5.701.021
5.752.330
5.786.536
5.820.742
492
M-1-60-iii
9.921.793
10.011.089
10.070.620
10.130.151
493
M-1-70-i
3.814.711
3.849.043
3.871.931
3.894.820
494
M-1-70-ii
7.783.899
7.853.954
7.900.658
7.947.361
495
M-1-70-iii
12.548.586
12.661.523
12.736.815
12.812.106
496
M-1-80-i
3.073.624
3.101.287
3.119.729
3.138.171
497
M-1-80-ii
4.646.692
4.688.512
4.716.392
4.744.272
498
M-1-80-iii
10.697.888
10.794.169
10.858.356
10.922.544
499
M-4-10-i
1.777.468
1.793.465
1.804.130
1.814.795
500
M-4-10-ii
2.969.966
2.996.695
3.014.515
3.032.335
501
M-4-10-iii
FRAKTUR FEMUR BERAT
6.306.565
6.363.324
6.401.164
6.439.003
502
M-4-11-i
2.576.176
2.599.362
2.614.819
2.630.276
503
M-4-11-ii
5.910.133
5.963.324
5.998.785
6.034.246
504
M-4-11-iii
10.490.347
10.584.760
10.647.703
10.710.645
505
M-4-12-i
1.777.468
1.793.465
1.804.130
1.814.795

TULANG WAJAH RINGAN
TULANG WAJAH SEDANG
TULANG WAJAH BERAT
SENDI MAYOR RINGAN
SENDI MAYOR SEDANG
SENDI MAYOR BERAT

RINGAN
SEDANG
BERAT

SELAIN KAKI (BERAT)

PANGGUL RINGAN
PANGGUL SEDANG
PANGGUL BERAT
PELVIS RINGAN
- 225 No
Kode
INA-CBG
506
M-4-12-ii
507
M-4-12-iii
508
M-4-13-i
509
M-4-13-ii
510
M-4-13-iii
511
M-4-14-i
512
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.234.100
3.263.207
3.282.612
3.302.017
7.109.871
7.173.860
7.216.519
7.259.178
3.593.526
3.625.868
3.647.429
3.668.991
4.443.669
4.483.662
4.510.324
4.536.986
10.689.841
10.786.049
10.850.188
10.914.328
3.554.935
3.586.930
3.608.259
3.629.589
M-4-14-ii
5.054.320
5.099.809
5.130.135
5.160.461
513
M-4-14-iii
OSTEOMIELITIS BERAT
7.570.827
7.638.965
7.684.390
7.729.814
514
M-4-15-i
2.428.894
2.450.754
2.465.327
2.479.900
515
M-4-15-ii
3.238.730
3.267.878
3.287.311
3.306.743
516
M-4-15-iii
7.554.238
7.622.226
7.667.551
7.712.877
517
M-4-16-i
2.426.547
2.448.386
2.462.945
2.477.505
518
M-4-16-ii
3.554.935
3.586.930
3.608.259
3.629.589
519
M-4-16-iii
7.238.988
7.304.139
7.347.573
7.391.007
520
M-4-17-i
2.221.835
2.241.831
2.255.162
2.268.493
521
M-4-17-ii
3.110.568
3.138.564
3.157.227
3.175.890
522
M-4-17-iii
4.344.074
4.383.171
4.409.235
4.435.299
523
M-4-18-i
2.852.092
2.877.761
2.894.873
2.911.986
524
M-4-18-ii
3.554.935
3.586.930
3.608.259
3.629.589
525
M-4-18-iii
4.836.982
4.880.515
4.909.536
4.938.558
526
M-4-19-i
2.120.569
2.139.654
2.152.378
2.165.101
527
M-4-19-ii
3.571.717
3.603.863
3.625.293
3.646.724
528
M-4-19-iii
6.653.003
6.712.880
6.752.798
6.792.716
529
M-4-20-i
1.777.468
1.793.465
1.804.130
1.814.795
530
M-4-20-ii
2.666.202
2.690.197
2.706.195
2.722.192
531
M-4-20-iii
2.954.780
2.981.373
2.999.101
3.016.830
532
M-4-21-i
1.777.468
1.793.465
1.804.130
1.814.795
533
M-4-21-ii
2.540.754
2.563.621
2.578.865
2.594.110
534
M-4-21-iii
6.193.285
6.249.025
6.286.185
6.323.344
535
N-1-01-i
4.809.347
4.852.631
4.881.487
4.910.343
536
N-1-01-ii
6.504.533
6.563.074
6.602.101
6.641.128

PELVIS SEDANG
PELVIS BERAT

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
RINGAN
SEDANG
BERAT
ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
- 226 No
Kode
INA-CBG
537
N-1-01-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
13.791.545
13.915.669
13.998.418
14.081.167
7.266.056
7.331.451
7.375.047
7.418.644
9.827.177
9.915.622
9.974.585
10.033.548
19.155.233
19.327.630
19.442.561
19.557.492
3.591.606
3.623.931
3.645.480
3.667.030
9.150.508
9.232.863
9.287.766
9.342.669
16.677.371
16.827.467
16.927.531
17.027.596
538
N-1-11-i
539
N-1-11-ii
540
N-1-11-iii
541
N-1-12-i
542
N-1-12-ii
543
N-1-12-iii
544
N-1-20-i
5.325.357
5.373.285
5.405.237
5.437.189
545
N-1-20-ii
10.558.289
10.653.313
10.716.663
10.780.013
546
N-1-20-iii
12.077.725
12.186.425
12.258.891
12.331.358
6.335.452
6.392.471
6.430.483
6.468.496
9.627.509
9.714.156
9.771.921
9.829.686
11.082.850
11.182.596
11.249.093
11.315.590
5.708.862
5.760.242
5.794.495
5.828.748
7.738.566
7.808.213
7.854.645
7.901.076
9.000.176
9.081.177
9.135.178
9.189.180
2.221.835
2.241.831
2.255.162
2.268.493
3.258.127
3.287.450
3.306.999
3.326.548
6.511.955
6.570.563
6.609.635
6.648.706


URIN BAWAH RINGAN
URIN BAWAH SEDANG
URIN BAWAH BERAT
RINGAN
SEDANG
BERAT
GINJAL RINGAN
GINJAL SEDANG
GINJAL BERAT
547
N-1-30-i
548
N-1-30-ii
549
N-1-30-iii
550
N-1-40-i
551
N-1-40-ii
552
N-1-40-iii
553
N-4-10-i
554
N-4-10-ii
555
N-4-10-iii
556
N-4-11-i
1.863.355
1.880.125
1.891.305
1.902.485
557
N-4-11-ii
3.149.025
3.177.366
3.196.260
3.215.154
558
N-4-11-iii
3.603.512
3.635.944
3.657.565
3.679.186
559
N-4-12-i
1.801.777
1.817.993
1.828.804
1.839.615
560
N-4-12-ii
2.666.202
2.690.197
2.706.195
2.722.192
561
N-4-12-iii
4.426.771
4.466.612
4.493.172
4.519.733
562
N-4-13-i
BATU URIN RINGAN
2.568.114
2.591.227
2.606.636
2.622.045
563
N-4-13-ii
BATU URIN SEDANG
3.096.180
3.124.046
3.142.623
3.161.200
564
N-4-13-iii
BATU URIN BERAT
7.625.043
7.693.668
7.739.418
7.785.169
565
N-4-14-i
1.539.616
1.553.473
1.562.711
1.571.948
566
N-4-14-ii
2.370.816
2.392.153
2.406.378
2.420.603

(RINGAN)
(SEDANG)
- 227 No
Kode
INA-CBG
567
N-4-14-iii
568
N-4-15-i
569
N-4-15-ii
570
N-4-15-iii
571
N-4-16-i
572
N-4-16-ii
573
N-4-16-iii
574
O-6-10-i
575
O-6-10-ii
576
O-6-10-iii
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
584
O-6-13-ii
585
O-6-13-iii
586
P-8-01-i
587
P-8-01-ii
588
P-8-01-iii
589
P-8-02-i
590
P-8-02-ii
591
P-8-02-iii
592
P-8-03-i
593
P-8-03-ii
594
P-8-03-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.844.707
3.879.310
3.902.378
3.925.446
2.501.437
2.523.950
2.538.959
2.553.967
3.432.750
3.463.645
3.484.241
3.504.838
3.917.387
3.952.644
3.976.148
3.999.652
2.512.239
2.534.849
2.549.922
2.564.996
3.554.935
3.586.930
3.608.259
3.629.589
7.475.500
7.542.780
7.587.633
7.632.486
3.124.760
3.152.883
3.171.631
3.190.380
3.468.960
3.500.181
3.520.994
3.541.808
4.274.934
4.313.408
4.339.058
4.364.707
1.972.703
1.990.457
2.002.293
2.014.129
3.214.111
3.243.038
3.262.323
3.281.607
5.446.921
5.495.943
5.528.625
5.561.306
2.181.654
2.201.289
2.214.379
2.227.469
2.620.161
2.643.743
2.659.463
2.675.184
3.291.857
3.321.484
3.341.235
3.360.986
1.613.201
1.627.719
1.637.399
1.647.078
1.806.069
1.822.324
1.833.160
1.843.997
2.246.086
2.266.301
2.279.777
2.293.254
44.660.366
45.062.309
45.330.272
45.598.234
55.260.217
55.757.559
56.089.120
56.420.682
64.860.004
65.443.744
65.832.904
66.222.064
59.257.092
59.790.406
60.145.948
60.501.491
67.973.984
68.585.750
68.993.594
69.401.438
77.665.137
78.364.123
78.830.114
79.296.105
2.993.005
3.019.942
3.037.900
3.055.858
4.190.207
4.227.919
4.253.060
4.278.201
6.600.527
6.659.931
6.699.535
6.739.138

(BERAT)
SALURAN URIN RINGAN
SALURAN URIN SEDANG
SALURAN URIN BERAT
RINGAN
SEDANG
BERAT
&KURET RINGAN
KURET SEDANG
KURET BERAT

- 228 No
Kode
INA-CBG
595
P-8-04-i
596
P-8-04-ii
597
P-8-04-iii
598
P-8-05-i
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii
603
P-8-06-iii
604
P-8-07-i
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
614
P-8-11-ii
615
P-8-11-iii
616
P-8-12-i
617
P-8-12-ii
618
P-8-12-iii
619
P-8-13-i
620
P-8-13-ii
621
P-8-13-iii
622
P-8-14-i
Deskripsi (INA-CBG)
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
RINGAN
SEDANG
BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
29.272.494
29.535.947
29.711.582
29.887.217
37.989.386
38.331.291
38.559.227
38.787.164
54.467.218
54.957.423
55.284.226
55.611.030
15.917.433
16.060.690
16.156.195
16.251.699
22.560.816
22.763.863
22.899.228
23.034.593
33.240.334
33.539.497
33.738.939
33.938.381
2.394.404
2.415.954
2.430.320
2.444.687
6.598.116
6.657.499
6.697.088
6.736.677
12.273.249
12.383.708
12.457.348
12.530.987
4.230.049
4.268.119
4.293.500
4.318.880
11.748.332
11.854.067
11.924.557
11.995.047
15.563.626
15.703.699
15.797.081
15.890.463
3.325.443
3.355.372
3.375.325
3.395.277
4.720.934
4.763.422
4.791.748
4.820.074
6.664.509
6.724.490
6.764.477
6.804.464
2.063.101
2.081.669
2.094.047
2.106.426
2.988.702
3.015.600
3.033.533
3.051.465
5.867.703
5.920.512
5.955.718
5.990.925
2.499.069
2.521.561
2.536.555
2.551.550
12.370.542
12.481.877
12.556.101
12.630.324
12.629.707
12.743.375
12.819.153
12.894.931
2.741.274
2.765.946
2.782.393
2.798.841
4.262.205
4.300.565
4.326.138
4.351.711
5.028.501
5.073.757
5.103.928
5.134.099
1.416.838
1.429.590
1.438.091
1.446.592
2.621.848
2.645.445
2.661.176
2.676.907
3.921.254
3.956.545
3.980.073
4.003.600
2.588.711
2.612.009
2.627.541
2.643.074
- 229 No
Kode
INA-CBG
623
P-8-14-ii
624
P-8-14-iii
625
P-8-15-i
626
P-8-15-ii
627
P-8-15-iii
628
P-8-16-i
629
P-8-16-ii
630
P-8-16-iii
631
P-8-17-i
632
P-8-17-ii
633
P-8-17-iii
634
S-4-10-i
635
S-4-10-ii
636
S-4-10-iii
637
S-4-11-i
638
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.285.415
5.332.983
5.364.696
5.396.408
5.798.080
5.850.263
5.885.051
5.919.840
1.946.791
1.964.312
1.975.993
1.987.674
3.891.124
3.926.144
3.949.491
3.972.837
4.570.727
4.611.864
4.639.288
4.666.712
1.762.306
1.778.167
1.788.741
1.799.315
2.499.906
2.522.406
2.537.405
2.552.405
3.245.002
3.274.207
3.293.677
3.313.147
1.161.007
1.171.456
1.178.422
1.185.388
3.863.485
3.898.257
3.921.438
3.944.618
7.798.199
7.868.383
7.915.172
7.961.961
1.777.468
1.793.465
1.804.130
1.814.795
2.221.835
2.241.831
2.255.162
2.268.493
2.888.004
2.913.996
2.931.324
2.948.652
1.110.917
1.120.916
1.127.581
1.134.247
S-4-11-ii
1.777.468
1.793.465
1.804.130
1.814.795
639
S-4-11-iii
2.735.479
2.760.098
2.776.511
2.792.924
640
S-4-12-i
1.333.101
1.345.099
1.353.097
1.361.096
641
S-4-12-ii
1.777.468
1.793.465
1.804.130
1.814.795
642
S-4-12-iii
3.471.535
3.502.779
3.523.608
3.544.437
643
S-4-13-i
1.777.468
1.793.465
1.804.130
1.814.795
644
S-4-13-ii
3.142.164
3.170.444
3.189.297
3.208.150
645
S-4-13-iii
6.397.846
6.455.427
6.493.814
6.532.201
646
S-4-14-i
1.082.978
1.092.725
1.099.223
1.105.721
647
S-4-14-ii
2.300.609
2.321.315
2.335.118
2.348.922
648
S-4-14-iii
4.362.775
4.402.040
4.428.217
4.454.393
649
S-4-15-i
819.067
826.438
831.353
836.267
650
S-4-15-ii
1.545.858
1.559.770
1.569.045
1.578.321
651
S-4-15-iii
2.002.245
2.020.265
2.032.278
2.044.292
652
S-4-16-i
LUKA BAKAR RINGAN
3.110.568
3.138.564
3.157.227
3.175.890
653
S-4-16-ii
LUKA BAKAR SEDANG
4.811.066
4.854.365
4.883.232
4.912.098
654
S-4-16-iii
LUKA BAKAR BERAT
8.590.905
8.668.223
8.719.769
8.771.314

ASPIRASI RINGAN
ASPIRASI SEDANG
ASPIRASI BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT

PASIEN RINGAN
PASIEN SEDANG
PASIEN BERAT
- 230 No
Kode
INA-CBG
655
S-4-17-i
656
S-4-17-ii
657
S-4-17-iii
658
T-1-10-i
659
T-1-10-ii
660
T-1-10-iii
661
T-4-10-i
662
T-4-10-ii
663
T-4-10-iii
664
T-4-11-i
665
T-4-11-ii
666
T-4-11-iii
667
T-4-12-i
668
T-4-12-ii
669
T-4-12-iii
670
U-1-10-i
671
U-1-10-ii
672
U-1-10-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.816.404
1.832.752
1.843.650
1.854.549
2.221.835
2.241.831
2.255.162
2.268.493
3.623.140
3.655.748
3.677.487
3.699.226
1.875.031
1.891.906
1.903.156
1.914.406
2.518.039
2.540.701
2.555.809
2.570.918
4.581.134
4.622.364
4.649.851
4.677.337
748.943
755.684
760.177
764.671
1.427.319
1.440.165
1.448.729
1.457.293
2.074.935
2.093.609
2.106.059
2.118.509
811.123
818.423
823.290
828.156
1.276.476
1.287.965
1.295.624
1.303.282
2.056.027
2.074.532
2.086.868
2.099.204
1.555.284
1.569.282
1.578.613
1.587.945
2.350.727
2.371.883
2.385.987
2.400.092
3.656.886
3.689.798
3.711.739
3.733.680
1.655.458
1.670.357
1.680.289
1.690.222
3.378.063
3.408.465
3.428.734
3.449.002
14.587.158
14.718.442
14.805.965
14.893.488
7.183.212
7.247.861
7.290.960
7.334.060
9.577.616
9.663.815
9.721.280
9.778.746
17.622.048
17.780.647
17.886.379
17.992.111

DOKTER RINGAN
DOKTER SEDANG
DOKTER BERAT

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
673
U-1-11-i
674
U-1-11-ii
675
U-1-11-iii
676
U-1-12-i
4.807.345
4.850.611
4.879.455
4.908.300
677
U-1-12-ii
10.774.818
10.871.792
10.936.441
11.001.089
678
U-1-12-iii
13.991.306
14.117.227
14.201.175
14.285.123
679
U-1-13-i
4.788.808
4.831.907
4.860.640
4.889.373
680
U-1-13-ii
5.917.083
5.970.337
6.005.839
6.041.342
681
U-1-13-iii
10.418.652
10.512.420
10.574.932
10.637.444
2.893.684
2.919.727
2.937.089
2.954.451
3.551.132
3.583.092
3.604.399
3.625.705
4.208.191
4.246.065
4.271.314
4.296.563
1.699.571
1.714.867
1.725.064
1.735.262
682
U-1-14-i
683
U-1-14-ii
684
U-1-14-iii
685
U-1-15-i

- 231 No
Kode
INA-CBG
686
U-1-15-ii
687
U-1-15-iii
688
U-1-20-i
689
U-1-20-ii
690
U-1-20-iii
691
U-1-30-i
692
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.414.971
2.436.706
2.451.196
2.465.686
4.758.798
4.801.627
4.830.180
4.858.733
4.396.049
4.435.614
4.461.990
4.488.366
7.824.968
7.895.392
7.942.342
7.989.292
17.627.530
17.786.178
17.891.943
17.997.708
3.771.044
3.804.983
3.827.609
3.850.235
U-1-30-ii
5.090.909
5.136.727
5.167.272
5.197.818
693
U-1-30-iii
9.577.616
9.663.815
9.721.280
9.778.746
694
U-4-10-i
3.510.212
3.541.804
3.562.865
3.583.926
695
U-4-10-ii
8.799.364
8.878.558
8.931.354
8.984.150
696
U-4-10-iii
12.836.355
12.951.882
13.028.901
13.105.919
697
U-4-11-i
1.777.468
1.793.465
1.804.130
1.814.795
698
U-4-11-ii
2.666.202
2.690.197
2.706.195
2.722.192
699
U-4-11-iii
4.038.132
4.074.476
4.098.704
4.122.933
700
U-4-12-i
1.777.468
1.793.465
1.804.130
1.814.795
701
U-4-12-ii
2.269.244
2.289.667
2.303.282
2.316.898
702
U-4-12-iii
3.607.994
3.640.466
3.662.114
3.683.762
703
U-4-13-i
1.777.468
1.793.465
1.804.130
1.814.795
704
U-4-13-ii
2.030.096
2.048.366
2.060.547
2.072.728
705
U-4-13-iii
2.524.308
2.547.026
2.562.172
2.577.318
706
U-4-14-i
2.221.835
2.241.831
2.255.162
2.268.493
707
U-4-14-ii
2.666.202
2.690.197
2.706.195
2.722.192
708
U-4-14-iii
4.466.350
4.506.547
4.533.345
4.560.143
1.777.468
1.793.465
1.804.130
1.814.795
2.221.835
2.241.831
2.255.162
2.268.493
3.111.171
3.139.172
3.157.839
3.176.506
5.196.127
5.242.893
5.274.069
5.305.246
5.986.010
6.039.884
6.075.800
6.111.716
11.373.419
11.475.780
11.544.021
11.612.261


DAN TELINGA RINGAN
DAN TELINGA SEDANG
DAN TELINGA BERAT


KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT
709
U-4-15-i
710
U-4-15-ii
711
U-4-15-iii
712
V-1-10-i
713
V-1-10-ii
714
V-1-10-iii
715
V-1-11-i
5.986.010
6.039.884
6.075.800
6.111.716
716
V-1-11-ii
6.680.488
6.740.612
6.780.695
6.820.778
717
V-1-11-iii
9.892.780
9.981.815
10.041.171
10.100.528
718
V-1-12-i

3.540.483
3.572.348
3.593.591
3.614.833
- 232 No
Kode
INA-CBG
719
V-1-12-ii
720
V-1-12-iii
721
V-1-13-i
722
V-1-13-ii
723
V-1-13-iii
724
V-1-14-i
725
V-1-14-ii
726
V-1-14-iii
727
V-1-15-i
728
V-1-15-ii
729
V-1-15-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
13.274.839
13.394.312
13.473.961
13.553.610
14.929.297
15.063.661
15.153.236
15.242.812
5.366.225
5.414.521
5.446.718
5.478.916
10.197.367
10.289.144
10.350.328
10.411.512
14.366.424
14.495.722
14.581.921
14.668.119
6.469.047
6.527.268
6.566.082
6.604.896
9.408.674
9.493.352
9.549.804
9.606.256
12.789.724
12.904.831
12.981.569
13.058.308
3.049.795
3.077.243
3.095.542
3.113.841
5.604.937
5.655.382
5.689.011
5.722.641
9.325.428
9.409.357
9.465.310
9.521.262
4.910.940
4.955.139
4.984.604
5.014.070
6.343.066
6.400.154
6.438.212
6.476.270
12.122.712
12.231.817
12.304.553
12.377.289
2.497.397
2.519.874
2.534.858
2.549.842
3.649.096
3.681.938
3.703.833
3.725.727
6.020.767
6.074.954
6.111.078
6.147.203
7.343.570
7.409.662
7.453.724
7.497.785
8.844.982
8.924.587
8.977.657
9.030.727
19.536.808
19.712.640
19.829.861
19.947.081

NON KOMPLEK (BERAT)

RINGAN
SEDANG
BERAT
730
V-4-10-i
731
V-4-10-ii
732
V-4-10-iii
733
V-4-11-i
734
V-4-11-ii
735
V-4-11-iii
736
W-1-01-i
737
W-1-01-ii
738
W-1-01-iii
739
W-1-10-i
2.045.176
2.063.582
2.075.853
2.088.124
740
W-1-10-ii
3.816.633
3.850.983
3.873.883
3.896.782
741
W-1-10-iii
6.242.801
6.298.986
6.336.443
6.373.900
742
W-1-11-i
2.124.257
2.143.375
2.156.121
2.168.867
743
W-1-11-ii
4.096.899
4.133.771
4.158.352
4.182.934
744
W-1-11-iii
7.183.212
7.247.861
7.290.960
7.334.060
745
W-1-12-i
1.930.207
1.947.579
1.959.160
1.970.741
746
W-1-12-ii
2.194.608
2.214.360
2.227.527
2.240.695
747
W-1-12-iii
3.371.195
3.401.536
3.421.763
3.441.990
748
W-1-13-i
2.097.831
2.116.711
2.129.298
2.141.885
749
W-1-13-ii
2.277.639
2.298.138
2.311.804
2.325.470
750
W-1-13-iii
3.059.290
3.086.824
3.105.179
3.123.535

SERVIK RINGAN
SERVIK SEDANG
SERVIK BERAT
ENDOSKOP RINGAN
ENDOSKOP SEDANG
ENDOSKOP BERAT
- 233 No
Kode
INA-CBG
751
W-1-20-i
752
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
6.259.767
6.316.105
6.353.664
6.391.222
W-1-20-ii
8.805.302
8.884.549
8.937.381
8.990.213
753
W-1-20-iii
10.774.818
10.871.792
10.936.441
11.001.089
754
W-1-30-i
3.417.205
3.447.960
3.468.463
3.488.966
755
W-1-30-ii
5.450.619
5.499.675
5.532.378
5.565.082
756
W-1-30-iii
14.494.537
14.624.988
14.711.955
14.798.922
757
W-4-10-i
2.548.379
2.571.314
2.586.605
2.601.895
758
W-4-10-ii
3.444.420
3.475.419
3.496.086
3.516.752
759
W-4-10-iii
7.109.871
7.173.860
7.216.519
7.259.178
760
W-4-11-i
2.221.835
2.241.831
2.255.162
2.268.493
761
W-4-11-ii
3.554.935
3.586.930
3.608.259
3.629.589
762
W-4-11-iii
4.320.300
4.359.183
4.385.105
4.411.026
763
W-4-12-i
1.777.468
1.793.465
1.804.130
1.814.795
764
W-4-12-ii
2.473.383
2.495.643
2.510.483
2.525.324
765
W-4-12-iii
2.984.027
3.010.883
3.028.787
3.046.691
766
W-4-13-i
ABORTUS RINGAN
974.784
983.557
989.406
995.255
767
W-4-13-ii
ABORTUS SEDANG
1.333.101
1.345.099
1.353.097
1.361.096
768
W-4-13-iii
ABORTUS BERAT
1.777.468
1.793.465
1.804.130
1.814.795
769
W-4-14-i
1.333.101
1.345.099
1.353.097
1.361.096
770
W-4-14-ii
1.777.468
1.793.465
1.804.130
1.814.795
771
W-4-14-iii
2.157.470
2.176.887
2.189.832
2.202.777
772
W-4-15-i
1.217.405
1.228.362
1.235.666
1.242.970
773
W-4-15-ii
1.353.986
1.366.172
1.374.296
1.382.420
774
W-4-15-iii
1.812.685
1.828.999
1.839.875
1.850.751
775
W-4-16-i
1.333.101
1.345.099
1.353.097
1.361.096
776
W-4-16-ii
1.935.073
1.952.489
1.964.099
1.975.709
777
W-4-16-iii
2.466.209
2.488.404
2.503.202
2.517.999
778
W-4-17-i
1.192.400
1.203.131
1.210.286
1.217.440
779
W-4-17-ii
1.777.468
1.793.465
1.804.130
1.814.795
780
W-4-17-iii
3.362.615
3.392.879
3.413.055
3.433.230
781
Z-4-10-i
REHABILITASI RINGAN
3.049.924
3.077.373
3.095.673
3.113.972
782
Z-4-10-ii
REHABILITASI SEDANG
4.048.334
4.084.769
4.109.059
4.133.349
783
Z-4-10-iii
REHABILITASI BERAT
5.751.045
5.802.804
5.837.310
5.871.816
784
Z-4-11-i
2.915.514
2.941.754
2.959.247
2.976.740

RINGAN
SEDANG
BERAT

- 234 No
Kode
INA-CBG
Deskripsi (INA-CBG)
785
Z-4-11-ii
786
Z-4-11-iii
787
Z-4-12-i
788
Z-4-12-ii
789
Z-4-12-iii
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.509.635
3.541.222
3.562.279
3.583.337
5.486.831
5.536.213
5.569.134
5.602.055
1.333.101
1.345.099
1.353.097
1.361.096
2.974.543
3.001.314
3.019.161
3.037.008
3.780.173
3.814.195
3.836.876
3.859.557

- 235 2. RawatJalan
No
Kode
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.105.814
1.115.766
1.122.401
1.129.036
1.434.414
1.447.324
1.455.930
1.464.537
2.667.481
2.691.489
2.707.494
2.723.499
2.204.415
2.224.254
2.237.481
2.250.707
1.841.598
1.858.173
1.869.222
1.880.272
645.673
651.484
655.358
659.232
1.439.765
1.452.723
1.461.362
1.470.000

295.824
298.487
300.262
302.037
C-3-10-0
806.967
814.230
819.072
823.913
10
C-3-11-0

KANDUNG KEMIH
1.276.249
1.287.735
1.295.393
1.303.050
11
C-3-12-0
289.323
291.927
293.663
295.399
280.952
283.481
285.167
286.852
2.391.753
2.413.278
2.427.629
2.441.979
2.192.136
2.211.866
2.225.019
2.238.171

LAPAROSKOPI
PANKREAS
LAPAROSKOPI
EMPEDU

OVARIUM
GASTROINTESTINAL
GINJAL ATAU PROSTAT
12
C-3-13-0
13
C-3-14-0
14
C-3-15-0
15
C-3-16-0
497.124
501.598
504.581
507.563
16
C-3-17-0

LEHER
329.777
332.745
334.724
336.703
17
C-3-18-0
146.209
147.525
148.402
149.279
18
C-3-19-0

MYELOMA ATAU TESTIS
206.769
208.630
209.871
211.111
19
C-3-20-0
4.117.817
4.154.878
4.179.584
4.204.291
20
C-3-21-0
235.961
238.084
239.500
240.916
21
C-3-22-0
1.035.993
1.045.317
1.051.533
1.057.749
22
C-3-23-0
167.808
169.319
170.325
171.332
23
D-2-10-0

TULANG
1.421.695
1.434.491
1.443.021
1.451.551
24
D-2-11-0
PROSEDUR LIMPA
1.780.205
1.796.227
1.806.908
1.817.590
25
D-2-21-0
1.493.088
1.506.526
1.515.484
1.524.443
26
D-2-22-0
327.688
330.637
332.603
334.569
27
D-3-10-0
237.352
239.489
240.913
242.337
28
D-3-11-0
616.235
621.781
625.479
629.176
29
E-2-10-0
365.546
368.836
371.029
373.223
30
E-2-21-0
265.008
267.393
268.984
270.574
31
E-2-22-0
265.008
267.393
268.984
270.574

TYMUS
TYMUS
TULANG
PEMBENTUK DARAH
PARATIROID
THYROGLOSSAL
- 236 No
Kode
INA-CBG
32
E-3-10-0
33
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

ENDOKRIN
308.188
310.961
312.810
314.660
F-3-10-0
TERAPI SHOCK
429.912
433.781
436.361
438.940
34
F-5-10-0
526.781
531.522
534.683
537.843
35
F-5-11-0
TERAPI KELOMPOK
347.364
350.490
352.574
354.658
36
F-5-12-0
444.511
448.511
451.178
453.846
37
F-5-13-0
376.471
379.859
382.118
384.377
38
F-5-14-0
252.562
254.835
256.350
257.866
39
F-5-15-0
236.935
239.068
240.489
241.911
40
F-5-16-0
246.791
249.012
250.493
251.974
41
G-2-10-0
207.817
209.687
210.934
212.181
42
G-2-11-0
1.801.446
1.817.659
1.828.467
1.839.276
43
G-2-12-0

EKSTRAKRANIAL
2.610.738
2.634.235
2.649.899
2.665.564
44
G-2-13-0
640.472
646.237
650.079
653.922
45
G-2-21-0
1.168.114
1.178.627
1.185.635
1.192.644
46
G-2-22-0
1.060.162
1.069.704
1.076.065
1.082.426
47
G-2-31-0
1.749.360
1.765.104
1.775.601
1.786.097
48
G-2-32-0
896.721
904.791
910.171
915.552
49
G-3-10-0
355.914
359.118
361.253
363.388
50
G-3-11-0
474.009
478.275
481.119
483.963
51
G-3-12-0
776.672
783.662
788.323
792.983
52
G-3-13-0
776.761
783.752
788.412
793.073
53
H-2-21-0
1.019.384
1.028.558
1.034.674
1.040.791
54
H-2-22-0
265.008
267.393
268.984
270.574
55
H-2-23-0
265.008
267.393
268.984
270.574
56
H-2-31-0
1.688.524
1.703.721
1.713.852
1.723.983
57
H-2-32-0
175.736
177.318
178.372
179.426
58
H-2-33-0
265.008
267.393
268.984
270.574
59
H-2-34-0
757.513
764.331
768.876
773.421
60
H-2-35-0
249.618
251.864
253.362
254.860
61
H-2-36-0
1.347.378
1.359.504
1.367.589
1.375.673
62
H-2-37-0

1.434.343
1.447.252
1.455.858
1.464.465
63
H-3-10-0
499.047
503.538
506.532
509.527
64
H-3-11-0
262.443
264.805
266.380
267.955

AKUT
MENTAL
PROSEDUR KRANIOTOMI

MATA
MATA
MATA
MATA
MATA
- 237 No
Kode
INA-CBG
65
H-3-12-0
66
H-3-13-0
67
I-2-11-0
68
I-2-12-0
69
I-2-13-0
70
I-2-14-0
71
I-2-15-0
Deskripsi (INA-CBG)
MATA
TORASIK
ABDOMEN
PENGGANTIAN ALAT
DARAH VENA
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
274.004
276.470
278.114
279.758
266.042
268.436
270.032
271.628
3.068.025
3.095.637
3.114.045
3.132.454
2.157.156
2.176.571
2.189.514
2.202.457
2.741.616
2.766.290
2.782.740
2.799.190
4.852.076
4.895.745
4.924.857
4.953.970
291.794
294.421
296.171
297.922
3.064.700
3.092.282
3.110.670
3.129.059
1.010.344
1.019.437
1.025.499
1.031.561
72
I-2-16-0
73
I-2-17-0
74
I-2-21-0
2.365.513
2.386.802
2.400.995
2.415.188
75
I-2-22-0
2.227.545
2.247.592
2.260.958
2.274.323
76
I-2-23-0
455.860
459.963
462.698
465.433
77
I-2-31-0
3.545.380
3.577.288
3.598.560
3.619.833
78
I-2-32-0
4.636.105
4.677.829
4.705.646
4.733.463
79
I-2-41-0
3.108.565
3.136.542
3.155.194
3.173.845
80
I-2-42-0

LAIN
3.614.221
3.646.749
3.668.435
3.690.120
81
I-3-10-0
PROSEDUR RESUSITASI
458.793
462.922
465.675
468.428
82
I-3-11-0
242.150
244.329
245.782
247.235
83
I-3-12-0
1.407.285
1.419.950
1.428.394
1.436.838
84
I-3-13-0
462.207
466.367
469.140
471.913
85
I-3-14-0
296.259
298.925
300.703
302.480

PACU JANTUNG

KARDIOVASKULAR
PERNAFASAN
PENDEK
262.443
264.805
266.380
267.955
1.624.880
1.639.504
1.649.253
1.659.002
261.930
264.288
265.859
267.431
86
I-3-15-0
87
J-2-10-0
88
J-2-21-0
89
J-2-22-0
1.319.965
1.331.845
1.339.765
1.347.684
90
J-2-31-0
PROSEDUR
1.712.113
1.727.522
1.737.794
1.748.067
91
J-2-32-0
1.274.096
1.285.563
1.293.207
1.300.852
92
J-3-10-0
265.008
267.393
268.984
270.574
93
J-3-11-0

PADA DADA
748.867
755.607
760.100
764.593
94
J-3-12-0
289.323
291.927
293.663
295.399
95
J-3-13-0
425.811
429.644
432.198
434.753
96
J-3-14-0
452.045
456.113
458.826
461.538
- 238 No
Kode
INA-CBG
97
J-3-15-0
98
J-3-16-0
99
J-3-17-0
100
K-2-10-0
101
K-2-11-0
102
K-2-12-0
103
K-2-13-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
396.407
399.975
402.353
404.732
452.045
456.113
458.826
461.538
265.008
267.393
268.984
270.574
762.785
769.650
774.227
778.803
1.628.857
1.643.517
1.653.290
1.663.063

1.250.358
1.261.611
1.269.113
1.276.615
2.035.025
2.053.340
2.065.551
2.077.761
265.008
267.393
268.984
270.574

PERNAFASAN
KECIL

FEMORALIS
USUS BESAR
ATAS
ATAS
265.008
267.393
268.984
270.574
3.405.989
3.436.643
3.457.079
3.477.515
1.145.261
1.155.568
1.162.440
1.169.312
265.008
267.393
268.984
270.574
1.261.529
1.272.883
1.280.452
1.288.021
104
K-2-14-0
105
K-2-21-0
106
K-2-22-0
107
K-2-31-0
108
K-2-32-0
109
K-2-41-0
110
K-2-42-0

360.434
363.678
365.841
368.003
111
K-2-51-0
835.965
843.489
848.505
853.521
112
K-2-52-0
455.860
459.963
462.698
465.433
113
K-2-53-0
265.008
267.393
268.984
270.574
114
K-3-10-0

GASTROINTESTINAL
504.293
508.832
511.858
514.883
115
K-3-11-0
303.179
305.907
307.726
309.546
116
K-3-12-0
307.461
310.229
312.073
313.918
117
K-3-13-0
265.008
267.393
268.984
270.574
710.229
716.621
720.882
725.143
342.979
346.066
348.124
350.182

GASTROINTESTINAL
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
454.469
458.559
461.286
464.013
1.562.482
1.576.544
1.585.919
1.595.294
1.001.540
1.010.554
1.016.563
1.022.572
452.045
456.113
458.826
461.538
455.860
459.963
462.698
465.433
1.365.020
1.377.305
1.385.495
1.393.685
306.152
308.907
310.744
312.581
118
K-3-14-0
119
K-3-15-0
120
K-3-16-0
121
L-2-21-0
122
L-2-22-0
123
L-2-31-0
124
L-2-32-0
125
L-2-41-0
126
L-2-42-0

127
L-2-51-0
2.043.648
2.062.041
2.074.303
2.086.565
L-2-52-0

1.563.458
1.577.529
1.586.910
1.596.291
128
- 239 No
Kode
INA-CBG
129
L-2-53-0
130
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

265.008
267.393
268.984
270.574
L-3-10-0
360.434
363.678
365.841
368.003
131
L-3-11-0
350.007
353.157
355.257
357.357
132
L-3-12-0
266.564
268.963
270.562
272.161
133
M-2-10-0
2.090.801
2.109.618
2.122.163
2.134.708
134
M-2-21-0
1.872.457
1.889.309
1.900.544
1.911.779
135
M-2-22-0
455.860
459.963
462.698
465.433
136
M-2-31-0
1.137.330
1.147.566
1.154.390
1.161.213
137
M-2-32-0
360.434
363.678
365.841
368.003
138
M-2-41-0

TULANG
360.434
363.678
365.841
368.003
139
M-2-42-0
124.216
125.334
126.079
126.824
140
M-2-51-0
265.008
267.393
268.984
270.574
141
M-2-52-0
265.008
267.393
268.984
270.574
142
M-2-61-0
PROSEDUR ARTROSKOPI
1.298.945
1.310.636
1.318.429
1.326.223
143
M-2-62-0
265.008
267.393
268.984
270.574
1.305.972
1.317.726
1.325.561
1.333.397
1.781.076
1.797.105
1.807.792
1.818.478
265.008
267.393
268.984
270.574
1.314.902
1.326.736
1.334.626
1.342.515
1.268.937
1.280.357
1.287.971
1.295.584

DAN WAJAH
PAHA
PAHA
PROSEDUR BUNION

TULANG
WAJAH
WAJAH
BAWAH
BAWAH
144
M-2-63-0
145
M-2-64-0
146
M-2-65-0
147
M-2-71-0
148
M-2-72-0
149
M-2-81-0
1.892.255
1.909.285
1.920.638
1.931.992
150
M-2-82-0
1.374.602
1.386.973
1.395.221
1.403.468
151
M-2-83-0
265.008
267.393
268.984
270.574
152
M-2-84-0
265.008
267.393
268.984
270.574
153
M-3-10-0
756.385
763.193
767.731
772.269
154
M-3-11-0
419.369
423.144
425.660
428.176
155
M-3-12-0
948.372
956.907
962.598
968.288
156
M-3-13-0
309.195
311.978
313.833
315.688
157
M-3-14-0

TERTUTUP
528.466
533.222
536.393
539.564
158
M-3-15-0
232.822
234.917
236.314
237.711
159
M-3-16-0

265.008
267.393
268.984
270.574
160
M-3-17-0
289.323
291.927
293.663
295.399
161
N-2-11-0
3.501.021
3.532.531
3.553.537
3.574.543

PERGELANGAN TANGAN
PERGELANGAN TANGAN
MUSKULOSKELETAL
SKELETAL
- 240 No
Kode
INA-CBG
162
N-2-12-0
163
N-2-21-0
164
N-2-22-0
165
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.025.306
2.043.534
2.055.686
2.067.838
2.014.631
2.032.762
2.044.850
2.056.938
455.860
459.963
462.698
465.433
N-2-23-0
455.860
459.963
462.698
465.433
166
N-2-24-0
1.473.187
1.486.446
1.495.285
1.504.124
167
N-2-31-0
1.240.185
1.251.347
1.258.788
1.266.229
168
N-2-32-0
455.860
459.963
462.698
465.433
169
N-2-41-0
455.860
459.963
462.698
465.433
170
N-2-42-0
770.947
777.886
782.511
787.137
171
N-3-10-0
455.860
459.963
462.698
465.433
172
N-3-11-0
528.179
532.933
536.102
539.271
173
N-3-12-0
408.147
411.821
414.270
416.718
174
N-3-13-0
455.860
459.963
462.698
465.433
175
N-3-14-0
392.243
395.773
398.127
400.480
176
N-3-15-0
1.005.810
1.014.862
1.020.897
1.026.932
177
O-7-10-0
167.927
169.438
170.446
171.453
178
O-7-11-0
924.818
933.141
938.690
944.239
179
O-7-12-0
336.757
339.788
341.809
343.829
180
O-7-13-0
187.155
188.839
189.962
191.085
181
P-9-10-0
249.618
251.864
253.362
254.860
182
P-9-11-0
249.618
251.864
253.362
254.860
183
P-9-12-0
249.618
251.864
253.362
254.860
184
P-9-13-0
249.618
251.864
253.362
254.860
185
P-9-14-0
249.618
251.864
253.362
254.860
186
P-9-15-0
159.112
160.544
161.498
162.453
187
P-9-16-0
249.618
251.864
253.362
254.860
188
P-9-17-0
248.544
250.781
252.272
253.764
189
Q-5-10-0
325.331
328.259
330.211
332.163
190
Q-5-11-0
243.827
246.022
247.484
248.947
191
Q-5-12-0
GIGI
214.903
216.837
218.126
219.416
192
Q-5-13-0
MEDICAL CHECK-UP
163.317
164.786
165.766
166.746
193
Q-5-14-0
179.702
181.319
182.397
183.475


DAN URETHRA
URETHRA
TRANSURETHRA
TRANSURETHRA
SALURAN KEMIH
KEMIH
KEMIH
PROSEDUR DIALISIS
CAESAR
VAGINAL/JALAN LAHIR

ASPIRASI
- 241 No
Kode
INA-CBG
194
Q-5-15-0
195
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
123.581
124.693
125.435
126.176
Q-5-16-0
VAKSINASI
139.675
140.932
141.770
142.608
196
Q-5-17-0
PASANG INFUS
120.815
121.902
122.627
123.352
197
Q-5-18-0
227.412
229.459
230.823
232.187
198
Q-5-19-0
254.233
256.521
258.046
259.572
199
Q-5-20-0
ABORSI MENGANCAM
170.404
171.937
172.960
173.982
200
Q-5-21-0
ABORSI
168.083
169.596
170.604
171.613
201
Q-5-22-0
179.702
181.319
182.397
183.475
202
Q-5-23-0
220.002
221.982
223.302
224.622
203
Q-5-24-0
150.258
151.611
152.512
153.414
204
Q-5-25-0
234.325
236.434
237.840
239.246
205
Q-5-26-0
BRONKIAL AKUT
331.671
334.656
336.646
338.636
206
Q-5-27-0
236.033
238.158
239.574
240.990
207
Q-5-28-0
191.535
193.259
194.408
195.557
208
Q-5-29-0

JANTUNG LAIN-LAIN
542.267
547.147
550.401
553.654
209
Q-5-30-0
628.429
634.084
637.855
641.626
210
Q-5-31-0
FRAKTUR
224.198
226.216
227.561
228.906
211
Q-5-32-0
SALURAN KEMIH AKUT
259.672
262.009
263.567
265.125
212
Q-5-33-0
HEMATOLOGI AKUT
271.876
274.323
275.954
277.585
213
Q-5-34-0
INFEKSI VIRUS HIV
386.218
389.694
392.012
394.329
214
Q-5-35-0
INFEKSI AKUT
437.961
441.903
444.531
447.158
215
Q-5-36-0
510.034
514.624
517.685
520.745
216
Q-5-37-0

SHOCK
260.143
262.485
264.046
265.606
217
Q-5-38-0
PARU AKUT
346.910
350.032
352.113
354.195
218
Q-5-39-0
221.997
223.995
225.327
226.659
219
Q-5-40-0
217.814
219.775
221.081
222.388
220
Q-5-41-0
301.533
304.247
306.056
307.865
221
Q-5-42-0
236.414
238.542
239.960
241.379
222
Q-5-43-0
340.450
343.514
345.556
347.599
223
Q-5-44-0
277.854
280.355
282.022
283.689
224
T-2-10-0

TERAPI DETOKSIKASI
144.118
145.415
146.280
147.145
225
U-2-10-0
1.923.421
1.940.731
1.952.272
1.963.812
226
U-2-11-0

LEHER
2.286.199
2.306.775
2.320.492
2.334.210
227
U-2-12-0
251.542
253.805
255.315
256.824
- 242 No
Kode
INA-CBG
228
U-2-13-0
229
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
329.777
332.745
334.724
336.703
U-2-14-0
612.577
618.090
621.765
625.441
230
U-2-15-0
348.053
351.185
353.273
355.362
231
U-2-21-0
405.427
409.076
411.508
413.941
232
U-2-22-0
783.318
790.367
795.067
799.767
233
U-2-23-0
1.026.399
1.035.637
1.041.795
1.047.953
234
U-2-24-0
865.031
872.817
878.007
883.197
235
U-2-25-0
329.777
332.745
334.724
336.703
236
U-2-31-0
265.008
267.393
268.984
270.574
237
U-2-32-0
329.777
332.745
334.724
336.703
238
U-3-10-0
315.284
318.122
320.014
321.905
239
U-3-11-0
334.734
337.746
339.755
341.763
240
U-3-12-0
148.019
149.351
150.239
151.127
241
U-3-13-0
325.357
328.285
330.237
332.190
242
U-3-14-0
298.936
301.626
303.420
305.214
243
U-3-15-0
260.699
263.045
264.609
266.173
244
U-3-16-0
PROSEDUR PADA GIGI
294.021
296.667
298.431
300.195
245
V-2-10-0

PROSTAT
2.868.514
2.894.330
2.911.541
2.928.753
246
V-2-11-0
323.495
326.407
328.348
330.289
1.032.320
1.041.611
1.047.805
1.053.998
455.860
459.963
462.698
465.433
455.860
459.963
462.698
465.433

(RHINOPLASTY)

RONGGA HIDUNG
TENGGOROKAN
PROSEDUR PADA PENIS

SKROTUM
SKROTUM
TRANSURETHRAL
247
V-2-12-0
248
V-2-13-0
249
V-2-14-0
250
V-2-15-0
SIRKUMSISI/SUNAT
249.618
251.864
253.362
254.860
251
V-3-10-0
520.594
525.280
528.403
531.527
252
V-3-11-0
1.101.327
1.111.239
1.117.847
1.124.455
253
V-3-12-0
635.825
641.548
645.363
649.178
254
W-2-10-0
232.822
234.917
236.314
237.711
255
W-2-11-0
595.005
600.361
603.931
607.501
256
W-2-12-0
1.101.327
1.111.239
1.117.847
1.124.455
257
W-2-13-0
176.633
178.223
179.283
180.343
258
W-2-21-0
2.213.961
2.233.887
2.247.171
2.260.454
259
W-2-22-0
232.822
234.917
236.314
237.711

PROSEDUR ABORSI
RAHIM & LEHER RAHIM
TERHALANG/TERGANGGU
TERHALANG/TERGANGGU
PANGGUL TERBUKA
PANGGUL TERBUKA
- 243 No
Kode
INA-CBG
260
W-2-23-0
Deskripsi (INA-CBG)
JALAN LAHIR
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
776.937
783.930
788.591
793.253
2.550.449
2.573.403
2.588.706
2.604.008
1.788.746
1.804.844
1.815.577
1.826.309
261
W-2-31-0
262
W-2-32-0
263
W-2-33-0
760.241
767.083
771.644
776.206
264
W-2-34-0
258.571
260.898
262.450
264.001
265
W-3-10-0
628.428
634.084
637.854
641.625
266
W-3-11-0
502.347
506.868
509.882
512.897
267
W-3-12-0
232.822
234.917
236.314
237.711
268
Z-3-10-0
2.635.852
2.659.574
2.675.390
2.691.205
269
Z-3-11-0

EMPEDU
2.014.631
2.032.762
2.044.850
2.056.938
270
Z-3-12-0
336.395
339.422
341.441
343.459
271
Z-3-13-0

LAIN-LAIN
2.052.772
2.071.247
2.083.564
2.095.880
272
Z-3-14-0
DIAGNOSTIK TIDUR
405.897
409.550
411.985
414.421
273
Z-3-15-0
265.008
267.393
268.984
270.574
274
Z-3-16-0

(MRI)
850.597
858.252
863.356
868.459
275
Z-3-17-0
PENGOBATAN NUKLIR
357.099
360.313
362.455
364.598
276
Z-3-18-0
CT-SCAN KEPALA
344.058
347.154
349.219
351.283
277
Z-3-19-0
CT SCAN LAIN-LAIN
358.097
361.320
363.469
365.617
278
Z-3-20-0
243.551
245.743
247.204
248.665
279
Z-3-21-0
232.822
234.917
236.314
237.711
280
Z-3-22-0
262.485
264.848
266.423
267.998
281
Z-3-23-0
273.401
275.862
277.502
279.143
282
Z-3-24-0
537.180
542.014
545.237
548.460
283
Z-3-25-0
239.259
241.412
242.848
244.284
284
Z-3-26-0
270.410
272.844
274.466
276.089
285
Z-3-27-0
PERAWATAN LUKA
258.168
260.492
262.041
263.590
286
Z-3-28-0
IMAGING PAYUDARA
265.008
267.393
268.984
270.574
287
Z-3-29-0
IMAGING LAIN-LAIN
763.802
770.676
775.259
779.842
288
Z-3-30-0
FOTOTERAPI
128.901
130.062
130.835
131.608
- 244 B. RUMAH SAKIT KHUSUS KELAS B PENDIDIKAN

1. RUMAH SAKIT JIWAKELAS B PENDIDIKAN
a. RawatInap
No
Kode
INA-CBG
A-4-10-i
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
SEPTIKEMIA RINGAN
2.465.712
2.539.683
2.588.998
2.638.312
A-4-10-ii
SEPTIKEMIA SEDANG
4.214.122
4.340.546
4.424.829
4.509.111
A-4-10-iii
SEPTIKEMIA BERAT
4.990.823
5.140.548
5.240.364
5.340.181
A-4-11-i
6.616.192
6.814.678
6.947.002
7.079.326
A-4-11-ii
10.221.252
10.527.890
10.732.315
10.936.740
A-4-11-iii
16.719.735
17.221.327
17.555.722
17.890.117
A-4-12-i
DEMAM RINGAN
1.929.531
1.987.417
2.026.008
2.064.598
A-4-12-ii
DEMAM SEDANG
3.722.564
3.834.241
3.908.692
3.983.143
A-4-12-iii
DEMAM BERAT
4.260.201
4.388.007
4.473.211
4.558.415
10
A-4-13-i
2.411.914
2.484.271
2.532.510
2.580.748
11
A-4-13-ii
2.894.297
2.981.126
3.039.012
3.096.897
12
A-4-13-iii
3.517.676
3.623.206
3.693.559
3.763.913
13
A-4-14-i
2.270.139
2.338.243
2.383.646
2.429.049
14
A-4-14-ii
3.702.592
3.813.670
3.887.722
3.961.774
15
A-4-14-iii
4.131.985
4.255.944
4.338.584
4.421.224
16
A-4-15-i
INFEKSI HIV RINGAN
3.034.736
3.125.778
3.186.473
3.247.167
17
A-4-15-ii
INFEKSI HIV SEDANG
4.341.445
4.471.688
4.558.517
4.645.346
18
A-4-15-iii
INFEKSI HIV BERAT
8.121.630
8.365.279
8.527.711
8.690.144
19
B-1-01-i
32.410.848
33.383.173
34.031.390
34.679.607
20
B-1-01-ii
35.757.830
36.830.565
37.545.722
38.260.879
21
B-1-01-iii
62.726.593
64.608.391
65.862.923
67.117.454
22
B-1-10-i
4.201.956
4.328.015
4.412.054
4.496.093
23
B-1-10-ii
10.708.609
11.029.867
11.244.039
11.458.212
24
B-1-10-iii
24.822.063
25.566.725
26.063.166
26.559.608
25
B-1-11-i
3.825.409
3.940.171
4.016.679
4.093.187
26
B-1-11-ii
9.602.136
9.890.201
10.082.243
10.274.286
27
B-1-11-iii
12.038.696
12.399.857
12.640.631
12.881.405
28
B-1-12-i
8.159.734
8.404.526
8.567.721
8.730.916
29
B-1-12-ii
17.488.307
18.012.956
18.362.722
18.712.488

LAIN-LAIN RINGAN
LAIN-LAIN SEDANG
LAIN-LAIN BERAT

(RINGAN)
(SEDANG)
(BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
- 245 No
Kode
INA-CBG
30
B-1-12-iii
31
B-1-13-i
32
B-1-13-ii
33
B-1-13-iii
34
B-1-14-i
35
B-1-14-ii
36
B-1-14-iii
37
B-4-10-i
38
B-4-10-ii
39
B-4-10-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
20.792.261
21.416.029
21.831.874
22.247.719
5.346.892
5.507.299
5.614.237
5.721.175
8.709.312
8.970.591
9.144.777
9.318.963
12.839.969
13.225.168
13.481.968
13.738.767
7.260.704
7.478.525
7.623.739
7.768.953
8.075.368
8.317.629
8.479.136
8.640.643
12.632.953
13.011.941
13.264.600
13.517.259
2.031.434
2.092.377
2.133.006
2.173.635
2.942.823
3.031.107
3.089.964
3.148.820
4.960.105
5.108.908
5.208.111
5.307.313
4.904.644
5.051.783
5.149.876
5.247.969
7.456.284
7.679.972
7.829.098
7.978.223
8.030.676
8.271.597
8.432.210
8.592.824
4.303.489
4.432.594
4.518.663
4.604.733
6.101.289
6.284.327
6.406.353
6.528.379
11.595.357
11.943.217
12.175.125
12.407.032
2.894.297
2.981.126
3.039.012
3.096.897
4.213.587
4.339.995
4.424.267
4.508.538
6.962.980
7.171.869
7.311.129
7.450.388
3.726.807
3.838.611
3.913.147
3.987.684
4.187.904
4.313.541
4.397.299
4.481.057
5.327.413
5.487.235
5.593.783
5.700.332

LAPAROSKOPIK BERAT
LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT

PANCREAS RINGAN
PANCREAS SEDANG
PANCREAS BERAT
(RINGAN)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT
40
B-4-11-i
41
B-4-11-ii
42
B-4-11-iii
43
B-4-12-i
44
B-4-12-ii
45
B-4-12-iii
46
B-4-13-i
47
B-4-13-ii
48
B-4-13-iii
49
B-4-14-i
50
B-4-14-ii
51
B-4-14-iii
52
C-4-10-i
3.791.118
3.904.852
3.980.674
4.056.496
53
C-4-10-ii
7.365.745
7.586.717
7.734.032
7.881.347
54
C-4-10-iii
LEUKEMIA AKUT BERAT
10.870.035
11.196.136
11.413.537
11.630.937
55
C-4-11-i
3.813.852
3.928.268
4.004.545
4.080.822
56
C-4-11-ii
4.369.985
4.501.084
4.588.484
4.675.884
57
C-4-11-iii
8.825.025
9.089.776
9.266.276
9.442.777
58
C-4-12-i
RADIOTERAPI RINGAN
1.929.531
1.987.417
2.026.008
2.064.598
59
C-4-12-ii
RADIOTERAPI SEDANG
7.145.966
7.360.345
7.503.264
7.646.184
60
C-4-12-iii
RADIOTERAPI BERAT
14.507.743
14.942.975
15.233.130
15.523.285
61
C-4-13-i
KEMOTERAPI RINGAN
1.929.531
1.987.417
2.026.008
2.064.598
- 246 No
Kode
INA-CBG
62
C-4-13-ii
63
C-4-13-iii
64
C-4-14-i
65
C-4-14-ii
66
C-4-14-iii
67
D-1-10-i
68
D-1-10-ii
69
D-1-10-iii
70
D-1-11-i
71
72
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
KEMOTERAPI SEDANG
3.859.062
3.974.834
4.052.015
4.129.197
KEMOTERAPI BERAT
5.049.298
5.200.776
5.301.762
5.402.748
3.365.561
3.466.528
3.533.839
3.601.150
4.917.973
5.065.512
5.163.872
5.262.231
7.497.308
7.722.227
7.872.173
8.022.119
20.739.219
21.361.396
21.776.180
22.190.964
31.587.421
32.535.044
33.166.792
33.798.541
42.809.587
44.093.875
44.950.066
45.806.258
5.676.707
5.847.008
5.960.542
6.074.076
D-1-11-ii
12.996.234
13.386.121
13.646.046
13.905.971
D-1-11-iii
20.370.615
20.981.733
21.389.145
21.796.558
5.198.494
5.354.448
5.458.418
5.562.388
14.317.204
14.746.720
15.033.064
15.319.408
22.743.410
23.425.712
23.880.580
24.335.448

RINGAN
SEDANG
BERAT
TULANG RINGAN
TULANG SEDANG
TULANG BERAT

73
D-1-20-i
74
D-1-20-ii
75
D-1-20-iii
76
D-4-10-i
2.236.069
2.303.151
2.347.872
2.392.593
77
D-4-10-ii
3.742.430
3.854.703
3.929.552
4.004.400
78
D-4-10-iii
5.236.369
5.393.460
5.498.187
5.602.915
79
D-4-11-i
2.411.914
2.484.271
2.532.510
2.580.748
80
D-4-11-ii
5.461.946
5.625.804
5.735.043
5.844.282
81
D-4-11-iii
8.274.088
8.522.310
8.687.792
8.853.274
82
D-4-12-i
2.499.073
2.574.045
2.624.027
2.674.008
83
D-4-12-ii
3.466.460
3.570.454
3.639.783
3.709.112
84
D-4-12-iii
5.322.751
5.482.434
5.588.889
5.695.344
1.929.531
1.987.417
2.026.008
2.064.598
2.894.297
2.981.126
3.039.012
3.096.897
3.999.702
4.119.693
4.199.687
4.279.681
2.411.914
2.484.271
2.532.510
2.580.748
5.427.955
5.590.794
5.699.353
5.807.912
6.474.800
6.669.044
6.798.540
6.928.036
6.221.489
6.408.133
6.532.563
6.656.993
8.149.558
8.394.045
8.557.036
8.720.027
16.153.780
16.638.394
16.961.469
17.284.545
4.760.372
4.903.183
4.998.391
5.093.598
85
D-4-13-i
86
D-4-13-ii
87
D-4-13-iii
88
D-4-14-i
89
D-4-14-ii
90
D-4-14-iii
91
E-1-01-i
92
E-1-01-ii
93
E-1-01-iii
94
E-1-10-i

RINGAN
SEDANG
BERAT
- 247 No
Kode
INA-CBG
95
E-1-10-ii
96
E-1-10-iii
97
E-1-20-i
98
E-1-20-ii
99
E-1-20-iii
100
E-4-10-i
101
E-4-10-ii
102
E-4-10-iii
103
E-4-11-i
104
E-4-11-ii
105
E-4-11-iii
106
E-4-12-i
107
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.777.974
5.951.314
6.066.873
6.182.433
12.178.269
12.543.617
12.787.183
13.030.748
7.341.114
7.561.348
7.708.170
7.854.992
9.832.237
10.127.204
10.323.849
10.520.493
21.785.458
22.439.022
22.874.731
23.310.440
3.012.265
3.102.633
3.162.878
3.223.123
4.614.036
4.752.457
4.844.738
4.937.019
7.826.228
8.061.015
8.217.540
8.374.064
2.768.042
2.851.083
2.906.444
2.961.805
5.236.660
5.393.759
5.498.492
5.603.226
8.635.493
8.894.558
9.067.268
9.239.977
2.653.105
2.732.698
2.785.761
2.838.823
E-4-12-ii
4.341.445
4.471.688
4.558.517
4.645.346
108
E-4-12-iii
6.975.048
7.184.299
7.323.800
7.463.301
109
E-4-13-i
3.488.684
3.593.344
3.663.118
3.732.892
110
E-4-13-ii
5.990.095
6.169.798
6.289.599
6.409.401
111
E-4-13-iii
10.364.377
10.675.308
10.882.596
11.089.883
112
F-4-10-i
SCHIZOFRENIA RINGAN
3.513.414
3.618.816
3.689.084
3.759.353
113
F-4-10-ii
SCHIZOFRENIA SEDANG
3.901.759
4.018.812
4.096.847
4.174.882
114
F-4-10-iii
SCHIZOFRENIA BERAT
5.776.640
5.949.939
6.065.472
6.181.005
115
F-4-11-i
3.238.516
3.335.672
3.400.442
3.465.212
116
F-4-11-ii
3.773.179
3.886.374
3.961.838
4.037.302
117
F-4-11-iii
DEPRESI MAYOR BERAT
4.838.595
4.983.752
5.080.524
5.177.296
118
F-4-12-i
1.777.467
1.830.791
1.866.341
1.901.890
119
F-4-12-ii
2.537.971
2.614.111
2.664.870
2.715.629
120
F-4-12-iii
5.505.703
5.670.874
5.780.988
5.891.102
121
F-4-13-i
2.617.213
2.695.730
2.748.074
2.800.418
122
F-4-13-ii
3.465.863
3.569.839
3.639.156
3.708.473
123
F-4-13-iii
4.468.788
4.602.851
4.692.227
4.781.603
124
F-4-14-i
DEPRESI RINGAN
1.832.050
1.887.011
1.923.652
1.960.293
125
F-4-14-ii
DEPRESI SEDANG
2.349.975
2.420.474
2.467.474
2.514.473
126
F-4-14-iii
DEPRESI BERAT
3.161.996
3.256.856
3.320.096
3.383.336
127
F-4-15-i
2.369.957
2.441.055
2.488.454
2.535.854

RINGAN
SEDANG
BERAT

RINGAN
SEDANG
BERAT

IMPULSE RINGAN
IMPULSE SEDANG
IMPULSE BERAT
- 248 No
Kode
INA-CBG
128
F-4-15-ii
129
F-4-15-iii
130
F-4-16-i
131
F-4-16-ii
132
F-4-16-iii
133
F-4-17-i
134
F-4-17-ii
135
F-4-17-iii
136
F-4-18-i
137
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.554.935
3.661.583
3.732.682
3.803.780
4.682.067
4.822.529
4.916.171
5.009.812
4.691.422
4.832.164
4.925.993
5.019.821
5.453.660
5.617.270
5.726.343
5.835.416
7.279.726
7.498.118
7.643.712
7.789.307
1.200.847
1.236.873
1.260.890
1.284.907
3.519.569
3.625.156
3.695.548
3.765.939
3.755.121
3.867.775
3.942.878
4.017.980
4.066.366
4.188.357
4.269.685
4.351.012
F-4-18-ii
4.474.151
4.608.376
4.697.859
4.787.342
138
F-4-18-iii
6.897.294
7.104.213
7.242.159
7.380.105
139
F-4-19-i
3.118.519
3.212.075
3.274.445
3.336.816
140
F-4-19-ii
3.993.344
4.113.144
4.193.011
4.272.878
141
F-4-19-iii
4.971.767
5.120.920
5.220.355
5.319.790
9.038.820
9.309.985
9.490.761
9.671.538
15.299.292
15.758.271
16.064.257
16.370.243
29.617.721
30.506.253
31.098.607
31.690.962

RINGAN
SEDANG
BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT
142
G-1-01-i
143
G-1-01-ii
144
G-1-01-iii
145
G-1-10-i
6.007.046
6.187.257
6.307.398
6.427.539
146
G-1-10-ii
8.480.455
8.734.869
8.904.478
9.074.087
147
G-1-10-iii
10.051.151
10.352.685
10.553.708
10.754.731
148
G-1-11-i
6.929.307
7.137.186
7.275.772
7.414.358
149
G-1-11-ii
14.229.853
14.656.749
14.941.346
15.225.943
150
G-1-11-iii
25.992.468
26.772.242
27.292.092
27.811.941
5.388.959
5.550.628
5.658.407
5.766.186
11.696.611
12.047.509
12.281.441
12.515.373
17.294.135
17.812.959
18.158.842
18.504.725

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT
151
G-1-12-i
152
G-1-12-ii
153
G-1-12-iii
154
G-1-13-i
1.067.239
1.099.256
1.120.601
1.141.946
155
G-1-13-ii
2.866.486
2.952.481
3.009.810
3.067.140
156
G-1-13-iii
6.468.000
6.662.040
6.791.400
6.920.760
6.790.547
6.994.263
7.130.074
7.265.885
9.174.251
9.449.479
9.632.964
9.816.449
22.462.075
23.135.937
23.585.179
24.034.420
8.660.731
8.920.553
9.093.768
9.266.982
157
G-1-20-i
158
G-1-20-ii
159
G-1-20-iii
160
G-1-30-i

RINGAN
SEDANG
BERAT
- 249 No
Kode
INA-CBG
161
G-1-30-ii
162
G-1-30-iii
163
G-4-10-i
164
G-4-10-ii
165
G-4-10-iii
166
G-4-11-i
167
G-4-11-ii
168
G-4-11-iii
169
G-4-12-i
170
G-4-12-ii
171
G-4-12-iii
172
G-4-13-i
173
G-4-13-ii
174
G-4-13-iii
175
G-4-14-i
176
G-4-14-ii
177
G-4-14-iii
178
G-4-15-i
179
G-4-15-ii
180
G-4-15-iii
181
G-4-16-i
182
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
22.605.339
23.283.499
23.735.605
24.187.712
29.100.056
29.973.058
30.555.059
31.137.060
2.894.297
2.981.126
3.039.012
3.096.897
3.958.119
4.076.862
4.156.025
4.235.187
6.938.885
7.147.052
7.285.829
7.424.607
6.423.378
6.616.079
6.744.547
6.873.014
7.451.118
7.674.652
7.823.674
7.972.696
10.919.742
11.247.334
11.465.729
11.684.124
4.804.121
4.948.245
5.044.327
5.140.410
6.053.193
6.234.788
6.355.852
6.476.916
8.791.542
9.055.288
9.231.119
9.406.950
2.672.981
2.753.170
2.806.630
2.860.089
3.713.942
3.825.360
3.899.639
3.973.918
4.335.169
4.465.224
4.551.927
4.638.631
4.888.483
5.035.138
5.132.908
5.230.677
8.043.205
8.284.501
8.445.365
8.606.229
10.070.276
10.372.384
10.573.790
10.775.195
3.237.168
3.334.283
3.399.026
3.463.770
4.019.991
4.140.590
4.220.990
4.301.390
5.924.017
6.101.738
6.220.218
6.338.698
2.701.475
2.782.519
2.836.549
2.890.578
G-4-16-ii
3.908.633
4.025.892
4.104.064
4.182.237
183
G-4-16-iii
6.877.316
7.083.635
7.221.181
7.358.728
184
G-4-17-i
4.636.360
4.775.451
4.868.178
4.960.905
185
G-4-17-ii
5.753.927
5.926.545
6.041.623
6.156.702
186
G-4-17-iii
9.643.629
9.932.937
10.125.810
10.318.683
187
G-4-18-i
2.918.752
3.006.315
3.064.690
3.123.065
188
G-4-18-ii
5.582.068
5.749.530
5.861.171
5.972.812
189
G-4-18-iii
5.913.632
6.091.041
6.209.314
6.327.587
190
G-4-19-i
3.242.538
3.339.815
3.404.665
3.469.516

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
DEGENERATIF RINGAN
DEGENERATIF SEDANG
DEGENERATIF BERAT
RINGAN
SEDANG
BERAT
TRAUMATIK RINGAN
TRAUMATIK SEDANG
TRAUMATIK BERAT
DENGAN INFARK BERAT
TANPA INFARK RINGAN
TANPA INFARK SEDANG
TANPA INFARK BERAT

PERIFER RINGAN
PERIFER SEDANG
PERIFER BERAT
PERSARAFAN RINGAN
PERSARAFAN SEDANG
PERSARAFAN BERAT
- 250 No
Kode
INA-CBG
191
G-4-19-ii
192
G-4-19-iii
193
G-4-20-i
194
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.743.622
5.915.931
6.030.803
6.145.676
8.171.197
8.416.333
8.579.757
8.743.181
1.904.186
1.961.312
1.999.395
2.037.479
G-4-20-ii
2.620.430
2.699.043
2.751.451
2.803.860
195
G-4-20-iii
4.328.212
4.458.058
4.544.623
4.631.187
196
G-4-21-i
2.631.558
2.710.505
2.763.136
2.815.767
197
G-4-21-ii
3.657.865
3.767.601
3.840.759
3.913.916
198
G-4-21-iii
6.421.001
6.613.631
6.742.051
6.870.471
199
G-4-22-i
1.929.531
1.987.417
2.026.008
2.064.598
200
G-4-22-ii
2.411.914
2.484.271
2.532.510
2.580.748
201
G-4-22-iii
2.767.096
2.850.109
2.905.451
2.960.793
202
G-4-23-i
2.373.309
2.444.508
2.491.974
2.539.440
203
G-4-23-ii
2.468.822
2.542.887
2.592.263
2.641.640
204
G-4-23-iii
3.514.996
3.620.446
3.690.746
3.761.046
205
G-4-24-i
1.986.986
2.046.595
2.086.335
2.126.075
206
G-4-24-ii
2.880.353
2.966.764
3.024.371
3.081.978
207
G-4-24-iii
TRAUMA KEPALA BERAT
5.563.560
5.730.467
5.841.738
5.953.009
208
G-4-25-i
GEGAR OTAK RINGAN
1.929.531
1.987.417
2.026.008
2.064.598
209
G-4-25-ii
GEGAR OTAK SEDANG
2.411.914
2.484.271
2.532.510
2.580.748
210
G-4-25-iii
GEGAR OTAK BERAT
3.011.733
3.102.085
3.162.319
3.222.554
211
G-4-26-i
3.911.296
4.028.635
4.106.861
4.185.087
212
G-4-26-ii
4.435.540
4.568.606
4.657.317
4.746.028
213
G-4-26-iii
6.510.502
6.705.818
6.836.028
6.966.238
214
H-1-20-i
3.730.630
3.842.549
3.917.162
3.991.775
215
H-1-20-ii
6.803.227
7.007.324
7.143.388
7.279.453
216
H-1-20-iii
9.251.964
9.529.523
9.714.562
9.899.601
217
H-1-30-i
3.652.643
3.762.222
3.835.275
3.908.328
218
H-1-30-ii
4.164.012
4.288.933
4.372.213
4.455.493
219
H-1-30-iii
6.947.504
7.155.929
7.294.879
7.433.830
220
H-4-10-i
3.308.682
3.407.943
3.474.117
3.540.290
221
H-4-10-ii
5.386.610
5.548.208
5.655.940
5.763.673
222
H-4-10-iii
8.457.657
8.711.387
8.880.540
9.049.693
223
H-4-11-i
2.650.791
2.730.314
2.783.330
2.836.346

SEDANG

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)

RINGAN
SEDANG
- 251 No
Kode
INA-CBG
224
H-4-11-ii
225
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.925.964
3.013.743
3.072.262
3.130.781
H-4-11-iii
3.882.132
3.998.596
4.076.239
4.153.881
226
H-4-12-i
3.677.866
3.788.202
3.861.759
3.935.317
227
H-4-12-ii
4.981.910
5.131.367
5.231.005
5.330.644
228
H-4-12-iii
8.311.977
8.561.336
8.727.576
8.893.815
229
I-1-01-i
42.046.422
43.307.815
44.148.744
44.989.672
230
I-1-01-ii
42.971.663
44.260.813
45.120.246
45.979.679
231
I-1-01-iii
67.829.946
69.864.844
71.221.443
72.578.042
232
I-1-02-i
23.327.113
24.026.926
24.493.469
24.960.011
233
I-1-02-ii
30.091.976
30.994.735
31.596.575
32.198.414
234
I-1-02-iii
37.090.110
38.202.813
38.944.615
39.686.417
235
I-1-03-i
14.222.476
14.649.150
14.933.599
15.218.049
236
I-1-03-ii
19.494.351
20.079.182
20.469.069
20.858.956
237
I-1-03-iii
28.591.715
29.449.467
30.021.301
30.593.135
238
I-1-04-i
23.338.875
24.039.041
24.505.819
24.972.596
239
I-1-04-ii
29.979.199
30.878.575
31.478.159
32.077.743
240
I-1-04-iii
63.909.429
65.826.712
67.104.900
68.383.089
241
I-1-05-i
30.874.120
31.800.344
32.417.826
33.035.309
242
I-1-05-ii
37.048.944
38.160.412
38.901.391
39.642.370
243
I-1-05-iii
50.979.113
52.508.487
53.528.069
54.547.651
244
I-1-06-i
19.380.657
19.962.076
20.349.689
20.737.303
245
I-1-06-ii
25.360.931
26.121.759
26.628.977
27.136.196
246
I-1-06-iii
27.994.318
28.834.147
29.394.034
29.953.920
247
I-1-07-i
25.487.031
26.251.642
26.761.382
27.271.123
248
I-1-07-ii
31.443.430
32.386.733
33.015.602
33.644.470
249
I-1-07-iii
34.304.578
35.333.715
36.019.807
36.705.898
250
I-1-11-i
4.848.255
4.993.702
5.090.668
5.187.633
251
I-1-11-ii
5.390.774
5.552.498
5.660.313
5.768.129
252
I-1-11-iii
7.173.478
7.388.682
7.532.152
7.675.621

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
KATETERISASI RINGAN
KATETERISASI SEDANG
KATETERISASI BERAT
RINGAN
SEDANG
BERAT

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
RINGAN
SEDANG
BERAT
- 252 No
Kode
INA-CBG
253
I-1-12-i
254
I-1-12-ii
255
I-1-12-iii
256
I-1-13-i
257
I-1-13-ii
258
I-1-13-iii
259
I-1-14-i
260
I-1-14-ii
261
I-1-14-iii
262
I-1-15-i
263
I-1-15-ii
264
I-1-15-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
12.392.862
12.764.648
13.012.505
13.260.362
16.717.114
17.218.628
17.552.970
17.887.312
22.828.956
23.513.825
23.970.404
24.426.983
7.570.372
7.797.483
7.948.891
8.100.298
8.512.220
8.767.587
8.937.831
9.108.076
18.537.753
19.093.886
19.464.641
19.835.396
24.013.205
24.733.601
25.213.865
25.694.129
29.844.983
30.740.332
31.337.232
31.934.132
39.107.219
40.280.435
41.062.580
41.844.724
7.641.715
7.870.966
8.023.800
8.176.635
14.000.147
14.420.151
14.700.154
14.980.157
24.158.025
24.882.766
25.365.926
25.849.087
10.291.373
10.600.115
10.805.942
11.011.770
26.757.571
27.560.298
28.095.449
28.630.601
30.864.201
31.790.127
32.407.411
33.024.695
4.395.294
4.527.153
4.615.059
4.702.965
9.104.247
9.377.375
9.559.460
9.741.545
52.780.889
54.364.315
55.419.933
56.475.551
6.944.436
7.152.769
7.291.658
7.430.546
11.696.611
12.047.509
12.281.441
12.515.373
22.545.537
23.221.903
23.672.814
24.123.725
11.675.617
12.025.885
12.259.397
12.492.910
24.287.641
25.016.270
25.502.023
25.987.776
37.637.023
38.766.133
39.518.874
40.271.614
20.909.039
21.536.310
21.954.490
22.372.671
26.952.538
27.761.114
28.300.165
28.839.216
32.415.309
33.387.768
34.036.075
34.684.381

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

DARAH VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
265
I-1-16-i
266
I-1-16-ii
267
I-1-16-iii
268
I-1-17-i
269
I-1-17-ii
270
I-1-17-iii
271
I-1-20-i
272
I-1-20-ii
273
I-1-20-iii
274
I-1-30-i
275
I-1-30-ii
276
I-1-30-iii
277
I-1-40-i
278
I-1-40-ii
279
I-1-40-iii
280
I-4-10-i
6.080.956
6.263.385
6.385.004
6.506.623
281
I-4-10-ii
9.601.939
9.889.997
10.082.035
10.274.074
- 253 No
Kode
INA-CBG
282
I-4-10-iii
283
I-4-11-i
284
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
13.851.634
14.267.183
14.544.216
14.821.248
6.218.481
6.405.036
6.529.406
6.653.775
I-4-11-ii
7.235.742
7.452.814
7.597.529
7.742.244
285
I-4-11-iii
11.739.972
12.092.171
12.326.970
12.561.770
286
I-4-12-i
6.315.582
6.505.049
6.631.361
6.757.672
287
I-4-12-ii
9.012.317
9.282.686
9.462.933
9.643.179
288
I-4-12-iii
10.933.208
11.261.205
11.479.869
11.698.533
289
I-4-13-i
5.673.128
5.843.322
5.956.785
6.070.247
290
I-4-13-ii
8.241.898
8.489.155
8.653.993
8.818.831
291
I-4-13-iii
13.564.047
13.970.968
14.242.249
14.513.530
292
I-4-14-i
3.528.162
3.634.007
3.704.570
3.775.133
293
I-4-14-ii
4.128.471
4.252.325
4.334.895
4.417.464
294
I-4-14-iii
6.397.757
6.589.689
6.717.645
6.845.600
3.859.062
3.974.834
4.052.015
4.129.197
7.430.935
7.653.863
7.802.482
7.951.101
8.469.478
8.723.563
8.892.952
9.062.342

VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT

295
I-4-15-i
296
I-4-15-ii
297
I-4-15-iii
298
I-4-16-i
3.004.725
3.094.867
3.154.961
3.215.056
299
I-4-16-ii
4.819.172
4.963.747
5.060.131
5.156.514
300
I-4-16-iii
6.050.180
6.231.685
6.352.689
6.473.693
301
I-4-17-i
HIPERTENSI RINGAN
3.484.266
3.588.794
3.658.480
3.728.165
302
I-4-17-ii
HIPERTENSI SEDANG
4.753.174
4.895.769
4.990.832
5.085.896
303
I-4-17-iii
HIPERTENSI BERAT
5.555.506
5.722.171
5.833.281
5.944.391
5.131.324
5.285.263
5.387.890
5.490.516
7.860.844
8.096.670
8.253.887
8.411.103
10.597.678
10.915.608
11.127.562
11.339.515
4.015.933
4.136.411
4.216.730
4.297.049
6.519.286
6.714.864
6.845.250
6.975.636
7.467.634
7.691.663
7.841.016
7.990.369

RINGAN
SEDANG
KONGENITAL BERAT
RINGAN
SEDANG
BERAT
304
I-4-18-i
305
I-4-18-ii
306
I-4-18-iii
307
I-4-19-i
308
I-4-19-ii
309
I-4-19-iii
310
I-4-20-i
4.873.904
5.020.121
5.117.599
5.215.077
311
I-4-20-ii
5.615.101
5.783.554
5.895.857
6.008.159
312
I-4-20-iii
7.452.174
7.675.739
7.824.783
7.973.826
313
I-4-21-i
6.481.503
6.675.948
6.805.578
6.935.208
314
I-4-21-ii
8.085.255
8.327.813
8.489.518
8.651.223
- 254 No
Kode
INA-CBG
315
I-4-21-iii
316
I-4-22-i
317
I-4-22-ii
318
I-4-22-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
11.030.002
11.360.902
11.581.502
11.802.102
3.135.488
3.229.553
3.292.263
3.354.972
3.613.021
3.721.411
3.793.672
3.865.932
5.271.299
5.429.438
5.534.864
5.640.290
2.399.224
2.471.200
2.519.185
2.567.169
2.945.694
3.034.064
3.092.978
3.151.892
5.755.617
5.928.285
6.043.397
6.158.510
3.810.753
3.925.075
4.001.290
4.077.505
9.514.395
9.799.827
9.990.115
10.180.403
12.029.234
12.390.111
12.630.696
12.871.280
30.702.063
31.623.125
32.237.166
32.851.208
32.798.903
33.782.870
34.438.848
35.094.826
56.037.118
57.718.232
58.838.974
59.959.716
15.694.286
16.165.114
16.479.000
16.792.886
16.812.762
17.317.145
17.653.400
17.989.655
24.844.471
25.589.805
26.086.695
26.583.584
6.124.137
6.307.861
6.430.344
6.552.827
14.792.017
15.235.778
15.531.618
15.827.458
22.366.749
23.037.751
23.485.086
23.932.421
5.198.494
5.354.448
5.458.418
5.562.388
7.698.562
7.929.519
8.083.490
8.237.461
10.101.168
10.404.203
10.606.227
10.808.250
3.569.507
3.676.592
3.747.982
3.819.372
15.318.139
15.777.683
16.084.046
16.390.409
41.781.754
43.035.206
43.870.841
44.706.476

RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
319
I-4-23-i
320
I-4-23-ii
321
I-4-23-iii
322
I-4-24-i
323
I-4-24-ii
324
I-4-24-iii
325
J-1-01-i
326
J-1-01-ii
327
J-1-01-iii
328
J-1-02-i
329
J-1-02-ii
330
J-1-02-iii
331
J-1-10-i
332
J-1-10-ii
333
J-1-10-iii
334
J-1-20-i
335
J-1-20-ii
336
J-1-20-iii
337
J-1-30-i
338
J-1-30-ii
339
J-1-30-iii
340
J-4-10-i
3.093.567
3.186.374
3.248.245
3.310.116
341
J-4-10-ii
4.423.429
4.556.132
4.644.600
4.733.069
342
J-4-10-iii
6.691.987
6.892.747
7.026.587
7.160.426
343
J-4-11-i
2.598.999
2.676.968
2.728.948
2.780.928
344
J-4-11-ii
3.617.747
3.726.279
3.798.634
3.870.989
345
J-4-11-iii
5.184.323
5.339.853
5.443.539
5.547.226
- 255 No
Kode
INA-CBG
346
J-4-12-i
347
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
EMBOLI PARU RINGAN
2.984.575
3.074.112
3.133.804
3.193.495
J-4-12-ii
EMBOLI PARU SEDANG
3.864.923
3.980.870
4.058.169
4.135.467
348
J-4-12-iii
EMBOLI PARU BERAT
5.161.214
5.316.050
5.419.274
5.522.499
349
J-4-13-i
6.122.307
6.305.976
6.428.422
6.550.868
350
J-4-13-ii
8.999.791
9.269.784
9.449.780
9.629.776
351
J-4-13-iii
14.632.313
15.071.282
15.363.928
15.656.574
352
J-4-14-i
TUMOR PARU RINGAN
4.172.158
4.297.323
4.380.766
4.464.210
353
J-4-14-ii
TUMOR PARU SEDANG
6.988.936
7.198.604
7.338.383
7.478.162
354
J-4-14-iii
TUMOR PARU BERAT
8.309.490
8.558.775
8.724.965
8.891.154
3.652.566
3.762.143
3.835.194
3.908.246
5.143.030
5.297.321
5.400.181
5.503.042
6.462.875
6.656.762
6.786.019
6.915.277
2.494.943
2.569.791
2.619.690
2.669.589
4.293.914
4.422.732
4.508.610
4.594.488
7.035.738
7.246.811
7.387.525
7.528.240

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
355
J-4-15-i
356
J-4-15-ii
357
J-4-15-iii
358
J-4-16-i
359
J-4-16-ii
360
J-4-16-iii
361
J-4-17-i
2.990.333
3.080.043
3.139.849
3.199.656
362
J-4-17-ii
4.058.750
4.180.512
4.261.687
4.342.862
363
J-4-17-iii
6.509.883
6.705.179
6.835.377
6.965.574
364
J-4-18-i
2.026.659
2.087.459
2.127.992
2.168.525
365
J-4-18-ii
3.100.788
3.193.812
3.255.828
3.317.843
366
J-4-18-iii
3.242.654
3.339.934
3.404.787
3.469.640
367
J-4-19-i
3.789.494
3.903.178
3.978.968
4.054.758
368
J-4-19-ii
5.142.992
5.297.282
5.400.142
5.503.001
369
J-4-19-iii
7.351.618
7.572.166
7.719.199
7.866.231
370
J-4-20-i
4.183.125
4.308.619
4.392.282
4.475.944
371
J-4-20-ii
5.540.375
5.706.587
5.817.394
5.928.202
372
J-4-20-iii
11.043.451
11.374.754
11.595.623
11.816.492
2.328.423
2.398.276
2.444.844
2.491.413
5.187.899
5.343.536
5.447.294
5.551.052
7.237.865
7.455.001
7.599.758
7.744.516
5.198.494
5.354.448
5.458.418
5.562.388
9.758.501
10.051.256
10.246.426
10.441.596
11.428.885
11.771.752
12.000.329
12.228.907
373
J-4-21-i
374
J-4-21-ii
375
J-4-21-iii
376
K-1-10-i
377
K-1-10-ii
378
K-1-10-iii

USUS BESAR (RINGAN)
USUS BESAR (SEDANG)
USUS BESAR (BERAT)
- 256 No
Kode
INA-CBG
Deskripsi (INA-CBG)
379
K-1-11-i
380
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
6.012.480
6.192.854
6.313.104
6.433.353
K-1-11-ii
7.893.660
8.130.470
8.288.343
8.446.216
381
K-1-11-iii
20.032.556
20.633.532
21.034.183
21.434.834
382
K-1-12-i
3.234.254
3.331.281
3.395.966
3.460.652
383
K-1-12-ii
4.215.233
4.341.690
4.425.995
4.510.300
384
K-1-12-iii
8.384.985
8.636.535
8.804.234
8.971.934
385
K-1-13-i
3.673.669
3.783.879
3.857.353
3.930.826
386
K-1-13-ii
6.416.845
6.609.350
6.737.687
6.866.024
387
K-1-13-iii
6.862.584
7.068.461
7.205.713
7.342.965
388
K-1-14-i
5.936.867
6.114.973
6.233.710
6.352.447
389
K-1-14-ii
6.973.522
7.182.728
7.322.198
7.461.669
390
K-1-14-iii
16.454.389
16.948.021
17.277.109
17.606.196
391
K-1-20-i
11.519.263
11.864.841
12.095.226
12.325.611
392
K-1-20-ii
16.077.853
16.560.189
16.881.746
17.203.303
393
K-1-20-iii
32.943.483
33.931.787
34.590.657
35.249.526
394
K-1-30-i
7.582.552
7.810.029
7.961.680
8.113.331
395
K-1-30-ii
10.396.987
10.708.897
10.916.837
11.124.776
396
K-1-30-iii
21.779.862
22.433.257
22.868.855
23.304.452
397
K-1-40-i
7.617.589
7.846.117
7.998.468
8.150.820
398
K-1-40-ii
8.382.400
8.633.872
8.801.520
8.969.168
399
K-1-40-iii
13.901.403
14.318.445
14.596.473
14.874.501
400
K-1-50-i
5.810.382
5.984.694
6.100.902
6.217.109
401
K-1-50-ii
7.524.719
7.750.461
7.900.955
8.051.450
402
K-1-50-iii
PROSEDUR ANAL BERAT
10.683.100
11.003.593
11.217.255
11.430.917
403
K-4-10-i
4.400.947
4.532.975
4.620.994
4.709.013
404
K-4-10-ii
5.265.991
5.423.971
5.529.291
5.634.611
405
K-4-10-iii
17.742.998
18.275.288
18.630.148
18.985.008
406
K-4-11-i
2.174.146
2.239.370
2.282.853
2.326.336
407
K-4-11-ii
3.528.519
3.634.375
3.704.945
3.775.515
408
K-4-11-iii
5.918.020
6.095.560
6.213.921
6.332.281
409
K-4-12-i
2.219.812
2.286.406
2.330.802
2.375.199
410
K-4-12-ii
3.877.512
3.993.838
4.071.388
4.148.938
411
K-4-12-iii
8.530.692
8.786.612
8.957.226
9.127.840


RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
- 257 No
Kode
INA-CBG
412
K-4-13-i
413
K-4-13-ii
414
K-4-13-iii
415
K-4-14-i
416
K-4-14-ii
417
K-4-14-iii
418
K-4-15-i
419
K-4-15-ii
420
K-4-15-iii
421
K-4-16-i
422
K-4-16-ii
423
K-4-16-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.053.355
3.144.955
3.206.022
3.267.090
3.916.488
4.033.983
4.112.313
4.190.642
6.323.089
6.512.782
6.639.244
6.765.706
2.514.871
2.590.317
2.640.614
2.690.912
3.375.812
3.477.086
3.544.603
3.612.119
5.926.851
6.104.657
6.223.194
6.341.731
2.656.097
2.735.780
2.788.902
2.842.024
4.800.615
4.944.633
5.040.645
5.136.658
6.737.432
6.939.555
7.074.304
7.209.053
2.670.307
2.750.416
2.803.822
2.857.228
3.536.086
3.642.169
3.712.890
3.783.612
4.752.065
4.894.627
4.989.668
5.084.710
1.929.531
1.987.417
2.026.008
2.064.598
3.786.762
3.900.364
3.976.100
4.051.835
4.603.387
4.741.489
4.833.557
4.925.625
2.586.963
2.664.572
2.716.312
2.768.051
4.029.164
4.150.039
4.230.622
4.311.205
4.684.986
4.825.535
4.919.235
5.012.935
26.559.553
27.356.339
27.887.530
28.418.721
27.354.811
28.175.455
28.722.552
29.269.648
38.338.891
39.489.057
40.255.835
41.022.613
9.097.364
9.370.285
9.552.232
9.734.179
17.449.584
17.973.072
18.322.063
18.671.055
18.403.867
18.955.983
19.324.060
19.692.137
4.864.079
5.010.001
5.107.283
5.204.565
10.396.987
10.708.897
10.916.837
11.124.776
14.914.907
15.362.355
15.660.653
15.958.951

(RINGAN)
(SEDANG)
RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
424
K-4-17-i
425
K-4-17-ii
426
K-4-17-iii
427
K-4-18-i
428
K-4-18-ii
429
K-4-18-iii
430
L-1-20-i
431
L-1-20-ii
432
L-1-20-iii
433
L-1-30-i
434
L-1-30-ii
435
L-1-30-iii
436
L-1-40-i
437
L-1-40-ii
438
L-1-40-iii
439
L-1-50-i
6.498.117
6.693.061
6.823.023
6.952.985
440
L-1-50-ii
11.696.611
12.047.509
12.281.441
12.515.373
441
L-1-50-iii
14.142.857
14.567.143
14.850.000
15.132.857
442
L-4-10-i
3.207.084
3.303.297
3.367.438
3.431.580
- 258 No
Kode
INA-CBG
443
L-4-10-ii
444
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.464.308
4.598.238
4.687.524
4.776.810
L-4-10-iii
9.188.036
9.463.677
9.647.438
9.831.199
445
L-4-11-i
3.682.187
3.792.653
3.866.297
3.939.941
446
L-4-11-ii
5.044.532
5.195.868
5.296.759
5.397.650
447
L-4-11-iii
13.680.141
14.090.545
14.364.148
14.637.751
448
L-4-12-i
3.634.968
3.744.017
3.816.716
3.889.415
449
L-4-12-ii
5.712.118
5.883.481
5.997.724
6.111.966
450
L-4-12-iii
9.250.571
9.528.088
9.713.099
9.898.110
451
L-4-13-i
2.443.597
2.516.905
2.565.777
2.614.649
452
L-4-13-ii
2.817.612
2.902.140
2.958.492
3.014.844
453
L-4-13-iii
4.226.637
4.353.436
4.437.969
4.522.502
454
L-4-14-i
2.226.856
2.293.662
2.338.199
2.382.736
455
L-4-14-ii
3.309.683
3.408.973
3.475.167
3.541.360
456
L-4-14-iii
6.086.971
6.269.580
6.391.320
6.513.059
457
M-1-01-i
9.501.927
9.786.985
9.977.023
10.167.062
458
M-1-01-ii
10.605.688
10.923.858
11.135.972
11.348.086
459
M-1-01-iii
14.898.118
15.345.061
15.643.024
15.940.986
460
M-1-02-i
8.962.024
9.230.885
9.410.126
9.589.366
461
M-1-02-ii
14.713.940
15.155.358
15.449.637
15.743.916
462
M-1-02-iii
25.282.765
26.041.248
26.546.903
27.052.558
16.895.104
17.401.957
17.739.860
18.077.762
19.772.213
20.365.379
20.760.824
21.156.268
25.731.382
26.503.324
27.017.951
27.532.579
5.911.979
6.089.338
6.207.578
6.325.817
7.579.096
7.806.468
7.958.050
8.109.632
9.483.809
9.768.324
9.958.000
10.147.676
9.209.728
9.486.020
9.670.214
9.854.409
10.643.977
10.963.297
11.176.176
11.389.056
18.129.592
18.673.480
19.036.072
19.398.664
7.634.068
7.863.090
8.015.772
8.168.453
10.227.266
10.534.084
10.738.629
10.943.175
20.833.911
21.458.928
21.875.606
22.292.284
463
M-1-03-i
464
M-1-03-ii
465
M-1-03-iii
466
M-1-04-i
467
M-1-04-ii
468
M-1-04-iii
469
M-1-05-i
470
M-1-05-ii
471
M-1-05-iii
472
M-1-07-i
473
M-1-07-ii
474
M-1-07-iii


- 259 No
Kode
INA-CBG
475
M-1-10-i
476
M-1-10-ii
477
M-1-10-iii
478
M-1-20-i
479
M-1-20-ii
480
M-1-20-iii
481
M-1-30-i
482
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
6.353.711
6.544.322
6.671.397
6.798.471
23.601.157
24.309.192
24.781.215
25.253.238
27.517.258
28.342.776
28.893.121
29.443.466
6.285.462
6.474.026
6.599.735
6.725.444
8.971.933
9.241.091
9.420.529
9.599.968
17.439.481
17.962.666
18.311.455
18.660.245
3.759.646
3.872.435
3.947.628
4.022.821
M-1-30-ii
7.768.384
8.001.436
8.156.804
8.312.171
483
M-1-30-iii
PROSEDUR KAKI BERAT
11.588.792
11.936.455
12.168.231
12.400.007
484
M-1-40-i
3.712.652
3.824.031
3.898.284
3.972.537
485
M-1-40-ii
6.110.856
6.294.181
6.416.398
6.538.615
486
M-1-40-iii
9.097.364
9.370.285
9.552.232
9.734.179
487
M-1-50-i
5.031.071
5.182.004
5.282.625
5.383.246
488
M-1-50-ii
9.097.364
9.370.285
9.552.232
9.734.179
489
M-1-50-iii
10.396.987
10.708.897
10.916.837
11.124.776
490
M-1-60-i
3.796.871
3.910.778
3.986.715
4.062.652
491
M-1-60-ii
7.601.361
7.829.402
7.981.429
8.133.457
492
M-1-60-iii
13.229.058
13.625.929
13.890.511
14.155.092
493
M-1-70-i
5.086.281
5.238.870
5.340.595
5.442.321
494
M-1-70-ii
10.378.533
10.689.888
10.897.459
11.105.030
495
M-1-70-iii
16.731.448
17.233.392
17.568.020
17.902.649
496
M-1-80-i
4.098.166
4.221.111
4.303.074
4.385.038
497
M-1-80-ii
6.195.589
6.381.457
6.505.368
6.629.280
498
M-1-80-iii
14.263.851
14.691.766
14.977.043
15.262.320
499
M-4-10-i
2.207.041
2.273.252
2.317.393
2.361.534
500
M-4-10-ii
3.959.954
4.078.753
4.157.952
4.237.151
501
M-4-10-iii
FRAKTUR FEMUR BERAT
8.408.754
8.661.016
8.829.191
8.997.366
502
M-4-11-i
3.434.902
3.537.949
3.606.647
3.675.345
503
M-4-11-ii
7.880.177
8.116.582
8.274.186
8.431.790
504
M-4-11-iii
13.987.130
14.406.744
14.686.486
14.966.229
505
M-4-12-i
1.929.531
1.987.417
2.026.008
2.064.598

TULANG WAJAH RINGAN
TULANG WAJAH SEDANG
TULANG WAJAH BERAT
SENDI MAYOR RINGAN
SENDI MAYOR SEDANG
SENDI MAYOR BERAT

RINGAN
SEDANG
BERAT

SELAIN KAKI (BERAT)

PANGGUL RINGAN
PANGGUL SEDANG
PANGGUL BERAT
PELVIS RINGAN
- 260 No
Kode
INA-CBG
506
M-4-12-ii
507
M-4-12-iii
508
M-4-13-i
509
M-4-13-ii
510
M-4-13-iii
511
M-4-14-i
512
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.510.780
3.616.103
3.686.319
3.756.534
7.718.125
7.949.668
8.104.031
8.258.393
4.791.369
4.935.110
5.030.937
5.126.764
5.363.967
5.524.886
5.632.166
5.739.445
14.253.121
14.680.715
14.965.777
15.250.840
3.859.062
3.974.834
4.052.015
4.129.197
M-4-14-ii
6.739.094
6.941.267
7.076.049
7.210.830
513
M-4-14-iii
OSTEOMIELITIS BERAT
8.746.498
9.008.893
9.183.823
9.358.753
514
M-4-15-i
3.238.525
3.335.681
3.400.451
3.465.222
515
M-4-15-ii
4.018.091
4.138.633
4.218.995
4.299.357
516
M-4-15-iii
9.033.592
9.304.600
9.485.272
9.665.944
517
M-4-16-i
3.235.396
3.332.458
3.397.166
3.461.874
518
M-4-16-ii
4.727.926
4.869.763
4.964.322
5.058.880
519
M-4-16-iii
9.651.984
9.941.544
10.134.583
10.327.623
520
M-4-17-i
2.771.894
2.855.051
2.910.489
2.965.927
521
M-4-17-ii
3.635.178
3.744.233
3.816.937
3.889.640
522
M-4-17-iii
4.987.692
5.137.323
5.237.076
5.336.830
523
M-4-18-i
3.802.789
3.916.873
3.992.929
4.068.985
524
M-4-18-ii
4.683.034
4.823.525
4.917.186
5.010.847
525
M-4-18-iii
6.449.309
6.642.788
6.771.774
6.900.761
526
M-4-19-i
2.827.425
2.912.248
2.968.797
3.025.345
527
M-4-19-ii
4.526.027
4.661.808
4.752.328
4.842.849
528
M-4-19-iii
7.222.171
7.438.836
7.583.280
7.727.723
529
M-4-20-i
2.107.874
2.171.110
2.213.267
2.255.425
530
M-4-20-ii
2.894.297
2.981.126
3.039.012
3.096.897
531
M-4-20-iii
3.207.563
3.303.790
3.367.941
3.432.092
532
M-4-21-i
2.019.861
2.080.457
2.120.854
2.161.252
533
M-4-21-ii
3.387.672
3.489.302
3.557.055
3.624.809
534
M-4-21-iii
6.994.550
7.204.387
7.344.278
7.484.169
535
N-1-01-i
5.273.352
5.431.552
5.537.019
5.642.486
536
N-1-01-ii
7.132.089
7.346.052
7.488.694
7.631.335

PELVIS SEDANG
PELVIS BERAT

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
RINGAN
SEDANG
BERAT
ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
- 261 No
Kode
INA-CBG
537
N-1-01-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
15.122.151
15.575.815
15.878.258
16.180.701
9.097.364
9.370.285
9.552.232
9.734.179
13.102.903
13.495.990
13.758.048
14.020.106
20.793.975
21.417.794
21.833.673
22.249.553
3.898.870
4.015.836
4.093.814
4.171.791
12.200.678
12.566.698
12.810.711
13.054.725
22.236.495
22.903.590
23.348.319
23.793.049
538
N-1-11-i
539
N-1-11-ii
540
N-1-11-iii
541
N-1-12-i
542
N-1-12-ii
543
N-1-12-iii
544
N-1-20-i
7.100.476
7.313.490
7.455.499
7.597.509
545
N-1-20-ii
14.077.719
14.500.050
14.781.604
15.063.159
546
N-1-20-iii
16.103.634
16.586.743
16.908.816
17.230.888
8.447.269
8.700.687
8.869.632
9.038.578
12.836.679
13.221.779
13.478.512
13.735.246
14.148.902
14.573.369
14.856.347
15.139.325
7.611.816
7.840.170
7.992.407
8.144.643
10.318.088
10.627.631
10.833.993
11.040.354
12.000.235
12.360.242
12.600.246
12.840.251
2.968.881
3.057.947
3.117.325
3.176.703
4.344.170
4.474.495
4.561.378
4.648.261
8.560.961
8.817.790
8.989.009
9.160.228


URIN BAWAH RINGAN
URIN BAWAH SEDANG
URIN BAWAH BERAT
RINGAN
SEDANG
BERAT
GINJAL RINGAN
GINJAL SEDANG
GINJAL BERAT
547
N-1-30-i
548
N-1-30-ii
549
N-1-30-iii
550
N-1-40-i
551
N-1-40-ii
552
N-1-40-iii
553
N-4-10-i
554
N-4-10-ii
555
N-4-10-iii
556
N-4-11-i
2.484.473
2.559.007
2.608.697
2.658.386
557
N-4-11-ii
4.198.699
4.324.660
4.408.634
4.492.608
558
N-4-11-iii
4.804.683
4.948.823
5.044.917
5.141.011
559
N-4-12-i
2.402.370
2.474.441
2.522.488
2.570.536
560
N-4-12-ii
3.376.466
3.477.760
3.545.289
3.612.818
561
N-4-12-iii
5.306.895
5.466.101
5.572.239
5.678.377
562
N-4-13-i
BATU URIN RINGAN
3.424.153
3.526.877
3.595.360
3.663.843
563
N-4-13-ii
BATU URIN SEDANG
4.128.240
4.252.088
4.334.652
4.417.217
564
N-4-13-iii
BATU URIN BERAT
10.166.724
10.471.725
10.675.060
10.878.394
565
N-4-14-i
1.688.158
1.738.803
1.772.566
1.806.329
566
N-4-14-ii
2.599.552
2.677.538
2.729.529
2.781.520

(RINGAN)
(SEDANG)
- 262 No
Kode
INA-CBG
567
N-4-14-iii
568
N-4-15-i
569
N-4-15-ii
570
N-4-15-iii
571
N-4-16-i
572
N-4-16-ii
573
N-4-16-iii
574
O-6-10-i
575
O-6-10-ii
576
O-6-10-iii
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
584
O-6-13-ii
585
O-6-13-iii
586
P-8-01-i
587
P-8-01-ii
588
P-8-01-iii
589
P-8-02-i
590
P-8-02-ii
591
P-8-02-iii
592
P-8-03-i
593
P-8-03-ii
594
P-8-03-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.215.644
4.342.113
4.426.426
4.510.739
3.335.249
3.435.307
3.502.012
3.568.717
4.577.000
4.714.310
4.805.850
4.897.390
5.223.183
5.379.878
5.484.342
5.588.806
3.349.652
3.450.141
3.517.134
3.584.127
4.322.644
4.452.323
4.538.776
4.625.229
8.621.464
8.880.108
9.052.537
9.224.967
4.166.347
4.291.337
4.374.664
4.457.991
4.625.280
4.764.038
4.856.544
4.949.050
5.699.912
5.870.909
5.984.907
6.098.906
2.630.270
2.709.178
2.761.784
2.814.389
4.285.481
4.414.046
4.499.756
4.585.465
7.262.561
7.480.438
7.625.689
7.770.940
2.908.872
2.996.138
3.054.316
3.112.493
3.493.548
3.598.355
3.668.226
3.738.096
4.389.143
4.520.817
4.608.600
4.696.383
2.061.289
2.123.128
2.164.354
2.205.580
2.408.092
2.480.335
2.528.497
2.576.659
2.994.782
3.084.625
3.144.521
3.204.416
48.969.191
50.438.267
51.417.650
52.397.034
60.591.714
62.409.465
63.621.299
64.833.134
71.117.686
73.251.217
74.673.571
76.095.924
79.009.457
81.379.740
82.959.930
84.540.119
90.631.980
93.350.939
95.163.579
96.976.218
103.553.517
106.660.122
108.731.193
110.802.263
3.249.059
3.346.530
3.411.511
3.476.493
4.839.352
4.984.533
5.081.320
5.178.107
8.794.927
9.058.775
9.234.674
9.410.572

(BERAT)
SALURAN URIN RINGAN
SALURAN URIN SEDANG
SALURAN URIN BERAT
RINGAN
SEDANG
BERAT
&KURET RINGAN
KURET SEDANG
KURET BERAT

- 263 No
Kode
INA-CBG
595
P-8-04-i
596
P-8-04-ii
597
P-8-04-iii
598
P-8-05-i
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii
603
P-8-06-iii
604
P-8-07-i
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
614
P-8-11-ii
615
P-8-11-iii
616
P-8-12-i
617
P-8-12-ii
618
P-8-12-iii
619
P-8-13-i
620
P-8-13-ii
621
P-8-13-iii
622
P-8-14-i
Deskripsi (INA-CBG)
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
RINGAN
SEDANG
BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
39.029.993
40.200.893
40.981.493
41.762.092
50.652.516
52.172.091
53.185.141
54.198.192
72.622.958
74.801.647
76.254.106
77.706.565
21.223.245
21.859.942
22.284.407
22.708.872
30.081.088
30.983.521
31.585.143
32.186.764
44.320.445
45.650.059
46.536.467
47.422.876
2.972.035
3.061.196
3.120.636
3.180.077
7.797.740
8.031.673
8.187.627
8.343.582
14.295.858
14.724.733
15.010.650
15.296.568
5.640.065
5.809.267
5.922.069
6.034.870
13.927.397
14.345.219
14.623.767
14.902.315
18.727.551
19.289.377
19.663.928
20.038.479
4.433.924
4.566.942
4.655.620
4.744.299
6.294.579
6.483.416
6.609.308
6.735.199
8.037.479
8.278.603
8.439.353
8.600.103
2.750.801
2.833.325
2.888.341
2.943.357
3.984.936
4.104.484
4.184.183
4.263.882
7.823.604
8.058.312
8.214.784
8.371.256
2.712.866
2.794.252
2.848.510
2.902.767
16.494.057
16.988.878
17.318.760
17.648.641
16.839.610
17.344.798
17.681.591
18.018.383
3.655.032
3.764.683
3.837.784
3.910.884
5.682.940
5.853.429
5.967.087
6.080.746
6.704.668
6.905.808
7.039.901
7.173.994
1.889.118
1.945.791
1.983.573
2.021.356
3.495.797
3.600.671
3.670.587
3.740.503
5.228.339
5.385.189
5.489.756
5.594.322
3.451.614
3.555.163
3.624.195
3.693.227
- 264 No
Kode
INA-CBG
623
P-8-14-ii
624
P-8-14-iii
625
P-8-15-i
626
P-8-15-ii
627
P-8-15-iii
628
P-8-16-i
629
P-8-16-ii
630
P-8-16-iii
631
P-8-17-i
632
P-8-17-ii
633
P-8-17-iii
634
S-4-10-i
635
S-4-10-ii
636
S-4-10-iii
637
S-4-11-i
638
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
7.047.220
7.258.636
7.399.581
7.540.525
7.730.774
7.962.697
8.117.312
8.271.928
2.595.722
2.673.593
2.725.508
2.777.422
5.188.165
5.343.810
5.447.573
5.551.337
6.094.303
6.277.132
6.399.018
6.520.904
2.349.742
2.420.234
2.467.229
2.514.223
3.333.209
3.433.205
3.499.869
3.566.533
4.326.669
4.456.469
4.543.002
4.629.536
1.548.009
1.594.449
1.625.409
1.656.369
5.151.314
5.305.853
5.408.879
5.511.906
10.397.598
10.709.526
10.917.478
11.125.430
1.929.531
1.987.417
2.026.008
2.064.598
2.411.914
2.484.271
2.532.510
2.580.748
3.135.074
3.229.126
3.291.828
3.354.529
1.205.957
1.242.136
1.266.255
1.290.374
S-4-11-ii
1.929.531
1.987.417
2.026.008
2.064.598
639
S-4-11-iii
2.969.501
3.058.586
3.117.976
3.177.366
640
S-4-12-i
1.487.339
1.531.959
1.561.706
1.591.452
641
S-4-12-ii
2.034.296
2.095.325
2.136.011
2.176.697
642
S-4-12-iii
3.891.807
4.008.561
4.086.398
4.164.234
643
S-4-13-i
2.311.564
2.380.911
2.427.142
2.473.373
644
S-4-13-ii
3.807.926
3.922.164
3.998.322
4.074.481
645
S-4-13-iii
7.377.715
7.599.047
7.746.601
7.894.155
646
S-4-14-i
1.187.464
1.223.088
1.246.837
1.270.586
647
S-4-14-ii
2.522.572
2.598.249
2.648.700
2.699.152
648
S-4-14-iii
4.783.695
4.927.206
5.022.880
5.118.553
649
S-4-15-i
898.090
925.033
942.994
960.956
650
S-4-15-ii
1.695.002
1.745.852
1.779.752
1.813.652
651
S-4-15-iii
2.195.421
2.261.284
2.305.192
2.349.100
652
S-4-16-i
LUKA BAKAR RINGAN
3.686.874
3.797.481
3.871.218
3.944.956
653
S-4-16-ii
LUKA BAKAR SEDANG
6.414.755
6.607.197
6.735.492
6.863.787
654
S-4-16-iii
LUKA BAKAR BERAT
11.454.540
11.798.176
12.027.267
12.256.358

ASPIRASI RINGAN
ASPIRASI SEDANG
ASPIRASI BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT

PASIEN RINGAN
PASIEN SEDANG
PASIEN BERAT
- 265 No
Kode
INA-CBG
655
S-4-17-i
656
S-4-17-ii
657
S-4-17-iii
658
T-1-10-i
659
T-1-10-ii
660
T-1-10-iii
661
T-4-10-i
662
T-4-10-ii
663
T-4-10-iii
664
T-4-11-i
665
T-4-11-ii
666
T-4-11-iii
667
T-4-12-i
668
T-4-12-ii
669
T-4-12-iii
670
U-1-10-i
671
U-1-10-ii
672
U-1-10-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.421.872
2.494.529
2.542.966
2.591.404
2.820.520
2.905.136
2.961.546
3.017.956
4.357.023
4.487.734
4.574.874
4.662.014
3.070.688
3.162.809
3.224.222
3.285.636
4.123.726
4.247.437
4.329.912
4.412.386
7.502.401
7.727.473
7.877.521
8.027.569
1.008.644
1.038.904
1.059.077
1.079.249
1.922.252
1.979.920
2.018.365
2.056.810
2.794.433
2.878.266
2.934.155
2.990.043
1.328.354
1.368.205
1.394.772
1.421.339
2.090.452
2.153.165
2.194.974
2.236.783
3.367.102
3.468.115
3.535.457
3.602.799
2.186.144
2.251.729
2.295.451
2.339.174
3.257.412
3.355.134
3.420.282
3.485.431
5.016.491
5.166.986
5.267.315
5.367.645
1.815.176
1.869.631
1.905.935
1.942.238
3.703.978
3.815.097
3.889.177
3.963.256
15.994.525
16.474.360
16.794.251
17.114.141

DOKTER RINGAN
DOKTER SEDANG
DOKTER BERAT

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
7.797.740
8.031.673
8.187.627
8.343.582
10.396.987
10.708.897
10.916.837
11.124.776
23.496.065
24.200.947
24.670.868
25.140.789
673
U-1-11-i
674
U-1-11-ii
675
U-1-11-iii
676
U-1-12-i
6.409.794
6.602.088
6.730.283
6.858.479
677
U-1-12-ii
11.696.611
12.047.509
12.281.441
12.515.373
678
U-1-12-iii
15.188.270
15.643.919
15.947.684
16.251.449
679
U-1-13-i
5.198.494
5.354.448
5.458.418
5.562.388
680
U-1-13-ii
6.498.117
6.693.061
6.823.023
6.952.985
681
U-1-13-iii
11.309.974
11.649.274
11.875.473
12.101.673
3.858.245
3.973.992
4.051.157
4.128.322
4.734.842
4.876.888
4.971.584
5.066.281
5.610.921
5.779.249
5.891.467
6.003.686
2.266.094
2.334.077
2.379.399
2.424.721
682
U-1-14-i
683
U-1-14-ii
684
U-1-14-iii
685
U-1-15-i

- 266 No
Kode
INA-CBG
686
U-1-15-ii
687
U-1-15-iii
688
U-1-20-i
689
U-1-20-ii
690
U-1-20-iii
691
U-1-30-i
692
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.219.962
3.316.561
3.380.960
3.445.359
6.345.064
6.535.416
6.662.317
6.789.219
5.861.399
6.037.241
6.154.469
6.271.697
9.213.909
9.490.327
9.674.605
9.858.883
19.135.576
19.709.643
20.092.355
20.475.066
5.028.058
5.178.900
5.279.461
5.380.022
U-1-30-ii
6.787.878
6.991.515
7.127.272
7.263.030
693
U-1-30-iii
10.396.987
10.708.897
10.916.837
11.124.776
694
U-4-10-i
4.680.282
4.820.691
4.914.296
5.007.902
695
U-4-10-ii
11.732.485
12.084.459
12.319.109
12.553.759
696
U-4-10-iii
17.115.140
17.628.595
17.970.898
18.313.200
697
U-4-11-i
2.172.018
2.237.178
2.280.619
2.324.059
698
U-4-11-ii
2.894.297
2.981.126
3.039.012
3.096.897
699
U-4-11-iii
5.384.177
5.545.702
5.653.385
5.761.069
700
U-4-12-i
1.929.531
1.987.417
2.026.008
2.064.598
701
U-4-12-ii
3.025.658
3.116.428
3.176.941
3.237.454
702
U-4-12-iii
4.810.659
4.954.979
5.051.192
5.147.405
703
U-4-13-i
1.929.531
1.987.417
2.026.008
2.064.598
704
U-4-13-ii
2.203.772
2.269.885
2.313.960
2.358.036
705
U-4-13-iii
3.365.744
3.466.716
3.534.031
3.601.346
706
U-4-14-i
2.411.914
2.484.271
2.532.510
2.580.748
707
U-4-14-ii
2.894.297
2.981.126
3.039.012
3.096.897
708
U-4-14-iii
4.879.183
5.025.558
5.123.142
5.220.726
2.078.375
2.140.726
2.182.294
2.223.861
2.737.136
2.819.250
2.873.992
2.928.735
3.712.275
3.823.644
3.897.889
3.972.135
6.411.311
6.603.651
6.731.877
6.860.103
7.277.402
7.495.724
7.641.272
7.786.820
12.346.422
12.716.815
12.963.744
13.210.672


DAN TELINGA RINGAN
DAN TELINGA SEDANG
DAN TELINGA BERAT


KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT
709
U-4-15-i
710
U-4-15-ii
711
U-4-15-iii
712
V-1-10-i
713
V-1-10-ii
714
V-1-10-iii
715
V-1-11-i
6.498.117
6.693.061
6.823.023
6.952.985
716
V-1-11-ii
7.252.008
7.469.568
7.614.608
7.759.648
717
V-1-11-iii
10.739.113
11.061.286
11.276.069
11.490.851
718
V-1-12-i

4.720.644
4.862.264
4.956.677
5.051.090
- 267 No
Kode
INA-CBG
719
V-1-12-ii
720
V-1-12-iii
721
V-1-13-i
722
V-1-13-ii
723
V-1-13-iii
724
V-1-14-i
725
V-1-14-ii
726
V-1-14-iii
727
V-1-15-i
728
V-1-15-ii
729
V-1-15-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
14.410.510
14.842.825
15.131.035
15.419.245
16.206.508
16.692.703
17.016.833
17.340.963
7.154.967
7.369.616
7.512.715
7.655.814
13.596.490
14.004.385
14.276.314
14.548.244
15.595.481
16.063.345
16.375.255
16.687.165
8.625.395
8.884.157
9.056.665
9.229.173
12.544.899
12.921.246
13.172.144
13.423.042
16.973.737
17.482.949
17.822.423
18.161.898
3.898.870
4.015.836
4.093.814
4.171.791
6.084.443
6.266.976
6.388.665
6.510.354
10.123.224
10.426.921
10.629.385
10.831.850
6.547.920
6.744.358
6.875.316
7.006.275
8.457.421
8.711.144
8.880.292
9.049.441
16.163.617
16.648.525
16.971.797
17.295.070
3.329.863
3.429.759
3.496.356
3.562.953
4.865.462
5.011.425
5.108.735
5.206.044
8.027.689
8.268.520
8.429.074
8.589.628
9.791.427
10.085.170
10.280.999
10.476.827
11.793.310
12.147.109
12.382.975
12.618.841
21.353.972
21.994.591
22.421.671
22.848.750

NON KOMPLEK (BERAT)

RINGAN
SEDANG
BERAT
730
V-4-10-i
731
V-4-10-ii
732
V-4-10-iii
733
V-4-11-i
734
V-4-11-ii
735
V-4-11-iii
736
W-1-01-i
737
W-1-01-ii
738
W-1-01-iii
739
W-1-10-i
2.599.247
2.677.224
2.729.209
2.781.194
740
W-1-10-ii
5.088.844
5.241.509
5.343.286
5.445.063
741
W-1-10-iii
8.323.734
8.573.446
8.739.921
8.906.396
742
W-1-11-i
2.832.343
2.917.313
2.973.960
3.030.607
743
W-1-11-ii
5.198.494
5.354.448
5.458.418
5.562.388
744
W-1-11-iii
7.797.740
8.031.673
8.187.627
8.343.582
745
W-1-12-i
2.573.609
2.650.818
2.702.290
2.753.762
746
W-1-12-ii
2.926.144
3.013.929
3.072.452
3.130.975
747
W-1-12-iii
4.494.927
4.629.775
4.719.673
4.809.572
748
W-1-13-i
2.300.229
2.369.236
2.415.240
2.461.245
749
W-1-13-ii
2.497.386
2.572.307
2.622.255
2.672.203
750
W-1-13-iii
3.354.450
3.455.083
3.522.172
3.589.261

SERVIK RINGAN
SERVIK SEDANG
SERVIK BERAT
ENDOSKOP RINGAN
ENDOSKOP SEDANG
ENDOSKOP BERAT
- 268 No
Kode
INA-CBG
751
W-1-20-i
752
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
8.346.356
8.596.747
8.763.674
8.930.601
W-1-20-ii
10.396.987
10.708.897
10.916.837
11.124.776
753
W-1-20-iii
11.696.611
12.047.509
12.281.441
12.515.373
754
W-1-30-i
4.556.274
4.692.962
4.784.087
4.875.213
755
W-1-30-ii
6.498.117
6.693.061
6.823.023
6.952.985
756
W-1-30-iii
19.326.050
19.905.831
20.292.352
20.678.873
757
W-4-10-i
3.397.839
3.499.774
3.567.731
3.635.687
758
W-4-10-ii
4.592.560
4.730.336
4.822.188
4.914.039
759
W-4-10-iii
8.255.644
8.503.313
8.668.426
8.833.539
760
W-4-11-i
2.411.914
2.484.271
2.532.510
2.580.748
761
W-4-11-ii
4.047.649
4.169.079
4.250.032
4.330.985
762
W-4-11-iii
4.886.856
5.033.462
5.131.199
5.228.936
763
W-4-12-i
1.929.531
1.987.417
2.026.008
2.064.598
764
W-4-12-ii
3.297.843
3.396.779
3.462.736
3.528.693
765
W-4-12-iii
3.978.702
4.098.063
4.177.637
4.257.211
766
W-4-13-i
ABORTUS RINGAN
1.058.178
1.089.923
1.111.087
1.132.250
767
W-4-13-ii
ABORTUS SEDANG
1.447.148
1.490.563
1.519.506
1.548.449
768
W-4-13-iii
ABORTUS BERAT
1.929.531
1.987.417
2.026.008
2.064.598
769
W-4-14-i
1.447.148
1.490.563
1.519.506
1.548.449
770
W-4-14-ii
1.929.531
1.987.417
2.026.008
2.064.598
771
W-4-14-iii
2.342.043
2.412.304
2.459.145
2.505.986
772
W-4-15-i
1.447.148
1.490.563
1.519.506
1.548.449
773
W-4-15-ii
1.555.324
1.601.984
1.633.091
1.664.197
774
W-4-15-iii
1.967.761
2.026.794
2.066.149
2.105.504
775
W-4-16-i
1.628.532
1.677.388
1.709.959
1.742.529
776
W-4-16-ii
2.580.097
2.657.500
2.709.102
2.760.704
777
W-4-16-iii
3.288.278
3.386.926
3.452.692
3.518.458
778
W-4-17-i
1.447.148
1.490.563
1.519.506
1.548.449
779
W-4-17-ii
1.929.531
1.987.417
2.026.008
2.064.598
780
W-4-17-iii
3.650.289
3.759.798
3.832.804
3.905.809
781
Z-4-10-i
REHABILITASI RINGAN
4.107.507
4.230.732
4.312.882
4.395.032
782
Z-4-10-ii
REHABILITASI SEDANG
5.452.122
5.615.686
5.724.728
5.833.771
783
Z-4-10-iii
REHABILITASI BERAT
7.745.259
7.977.617
8.132.522
8.287.428
784
Z-4-11-i
3.887.353
4.003.973
4.081.720
4.159.467

RINGAN
SEDANG
BERAT

- 269 No
Kode
INA-CBG
Deskripsi (INA-CBG)
785
Z-4-11-ii
786
Z-4-11-iii
787
Z-4-12-i
788
Z-4-12-ii
789
Z-4-12-iii
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.679.513
4.819.899
4.913.489
5.007.079
7.315.775
7.535.248
7.681.564
7.827.879
1.503.534
1.548.640
1.578.710
1.608.781
3.966.057
4.085.039
4.164.360
4.243.681
5.040.231
5.191.438
5.292.242
5.393.047

b. RawatJalan
No
Kode
INA-CBG
B-2-10-0
B-2-11-0
- 270 -
Deskripsi (INA-CBG)
LAPAROSKOPI
PANKREAS
LAPAROSKOPI
EMPEDU
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
800.166
824.171
840.174
856.178
1.037.940
1.069.079
1.089.837
1.110.596
1.930.187
1.988.093
2.026.696
2.065.300
1.595.112
1.642.966
1.674.868
1.706.770
1.332.579
1.372.556
1.399.208
1.425.859
467.208
481.224
490.568
499.913
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
1.041.813
1.073.067
1.093.903
1.114.739
B-3-12-0

214.058
220.480
224.761
229.042
C-3-10-0
583.921
601.438
613.117
624.795
10
C-3-11-0

KANDUNG KEMIH
923.492
951.197
969.667
988.137
11
C-3-12-0
209.354
215.634
219.822
224.009
12
C-3-13-0
203.297
209.396
213.462
217.528
13
C-3-14-0
1.730.670
1.782.590
1.817.203
1.851.817
14
C-3-15-0
1.586.228
1.633.815
1.665.539
1.697.264
15
C-3-16-0
359.718
370.510
377.704
384.899
16
C-3-17-0

LEHER
238.627
245.785
250.558
255.330
17
C-3-18-0
105.797
108.971
111.087
113.202
18
C-3-19-0

MYELOMA ATAU TESTIS
149.618
154.107
157.099
160.091
19
C-3-20-0
2.979.648
3.069.038
3.128.631
3.188.224
20
C-3-21-0
170.741
175.863
179.278
182.693
21
C-3-22-0
749.644
772.133
787.126
802.119
22
C-3-23-0
121.426
125.069
127.497
129.926
23
D-2-10-0

TULANG
1.028.737
1.059.599
1.080.174
1.100.749
24
D-2-11-0
PROSEDUR LIMPA
1.288.155
1.326.799
1.352.563
1.378.326
25
D-2-21-0
1.080.397
1.112.809
1.134.417
1.156.025
26
D-2-22-0
237.115
244.228
248.970
253.713
27
D-3-10-0
171.748
176.900
180.335
183.770
28
D-3-11-0
445.907
459.284
468.203
477.121
29
E-2-10-0
264.509
272.444
277.734
283.024
30
E-2-21-0
191.760
197.513
201.348
205.183
31
E-2-22-0
191.760
197.513
201.348
205.183

OVARIUM
GASTROINTESTINAL
GINJAL ATAU PROSTAT

TYMUS
TYMUS
TULANG
PEMBENTUK DARAH
PARATIROID
THYROGLOSSAL
- 271 No
Kode
INA-CBG
32
E-3-10-0
33
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

ENDOKRIN
223.004
229.694
234.155
238.615
F-3-10-0
TERAPI SHOCK
573.215
590.412
601.876
613.341
34
F-5-10-0
702.374
723.446
737.493
751.541
35
F-5-11-0
TERAPI KELOMPOK
463.151
477.046
486.309
495.572
36
F-5-12-0
592.681
610.461
622.315
634.168
37
F-5-13-0
501.961
517.020
527.059
537.098
38
F-5-14-0
336.749
346.851
353.586
360.321
39
F-5-15-0
315.914
325.391
331.709
338.028
40
F-5-16-0
329.054
338.926
345.507
352.088
41
G-2-10-0
150.376
154.887
157.895
160.903
42
G-2-11-0
1.303.524
1.342.630
1.368.700
1.394.771
43
G-2-12-0

EKSTRAKRANIAL
1.889.128
1.945.801
1.983.584
2.021.366
44
G-2-13-0
463.445
477.348
486.617
495.886
45
G-2-21-0
845.246
870.603
887.508
904.413
46
G-2-22-0
767.132
790.146
805.489
820.832
47
G-2-31-0
1.265.835
1.303.810
1.329.127
1.354.444
48
G-2-32-0
648.866
668.332
681.309
694.287
49
G-3-10-0
257.539
265.265
270.416
275.567
50
G-3-11-0
342.993
353.282
360.142
367.002
51
G-3-12-0
561.999
578.859
590.099
601.339
52
G-3-13-0
562.063
578.925
590.167
601.408
53
H-2-21-0
737.625
759.754
774.506
789.259
54
H-2-22-0
191.760
197.513
201.348
205.183
55
H-2-23-0
191.760
197.513
201.348
205.183
56
H-2-31-0
1.221.814
1.258.469
1.282.905
1.307.341
57
H-2-32-0
127.162
130.977
133.520
136.064
58
H-2-33-0
191.760
197.513
201.348
205.183
59
H-2-34-0
548.136
564.580
575.542
586.505
60
H-2-35-0
180.623
186.042
189.654
193.267
61
H-2-36-0
974.961
1.004.210
1.023.710
1.043.209
62
H-2-37-0

1.037.889
1.069.026
1.089.784
1.110.542
63
H-3-10-0
361.110
371.943
379.165
386.387
64
H-3-11-0
189.904
195.601
199.399
203.197

AKUT
MENTAL
PROSEDUR KRANIOTOMI

MATA
MATA
MATA
MATA
MATA
- 272 No
Kode
INA-CBG
65
H-3-12-0
66
H-3-13-0
67
I-2-11-0
68
I-2-12-0
69
I-2-13-0
70
I-2-14-0
71
I-2-15-0
Deskripsi (INA-CBG)
MATA
TORASIK
ABDOMEN
PENGGANTIAN ALAT
DARAH VENA
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
198.269
204.217
208.183
212.148
192.507
198.283
202.133
205.983
2.220.020
2.286.620
2.331.021
2.375.421
1.560.916
1.607.744
1.638.962
1.670.180
1.983.831
2.043.345
2.083.022
2.122.699
3.510.958
3.616.286
3.686.505
3.756.725
211.142
217.476
221.699
225.922
2.217.614
2.284.142
2.328.495
2.372.847
731.084
753.016
767.638
782.259
72
I-2-16-0
73
I-2-17-0
74
I-2-21-0
1.711.683
1.763.033
1.797.267
1.831.500
75
I-2-22-0
1.611.849
1.660.204
1.692.441
1.724.678
76
I-2-23-0
329.860
339.756
346.353
352.950
77
I-2-31-0
2.565.433
2.642.396
2.693.705
2.745.014
78
I-2-32-0
3.354.681
3.455.321
3.522.415
3.589.508
79
I-2-41-0
2.249.355
2.316.835
2.361.822
2.406.809
80
I-2-42-0

LAIN
2.615.247
2.693.704
2.746.009
2.798.314
81
I-3-10-0
PROSEDUR RESUSITASI
331.982
341.942
348.581
355.221
82
I-3-11-0
175.220
180.476
183.981
187.485
83
I-3-12-0
1.018.310
1.048.859
1.069.225
1.089.591
84
I-3-13-0
334.452
344.486
351.175
357.864
85
I-3-14-0
214.373
220.804
225.091
229.379
189.904
195.601
199.399
203.197
1.175.761
1.211.034
1.234.549
1.258.065
189.532
195.218
199.009
202.800
955.125
983.779
1.002.882
1.021.984
1.238.883
1.276.050
1.300.827
1.325.605

PACU JANTUNG

KARDIOVASKULAR
PERNAFASAN
PENDEK
86
I-3-15-0
87
J-2-10-0
88
J-2-21-0
89
J-2-22-0
90
J-2-31-0
91
J-2-32-0
921.935
949.593
968.031
986.470
92
J-3-10-0
191.760
197.513
201.348
205.183
93
J-3-11-0

PADA DADA
541.879
558.136
568.973
579.811
94
J-3-12-0
209.354
215.634
219.822
224.009
95
J-3-13-0
308.117
317.360
323.522
329.685
96
J-3-14-0
327.099
336.912
343.454
349.996
- 273 No
Kode
INA-CBG
97
J-3-15-0
98
J-3-16-0
99
J-3-17-0
100
K-2-10-0
101
K-2-11-0
102
K-2-12-0

103
K-2-13-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
286.840
295.445
301.182
306.919
327.099
336.912
343.454
349.996
191.760
197.513
201.348
205.183
551.950
568.509
579.548
590.587
1.178.639
1.213.999
1.237.571
1.261.144
904.758
931.900
949.996
968.091
1.472.542
1.516.718
1.546.169
1.575.620
191.760
197.513
201.348
205.183
191.760
197.513
201.348
205.183
2.464.571
2.538.508
2.587.799
2.637.091
828.710
853.571
870.145
886.719
191.760
197.513
201.348
205.183

PERNAFASAN
KECIL

FEMORALIS
USUS BESAR
ATAS
ATAS
104
K-2-14-0
105
K-2-21-0
106
K-2-22-0
107
K-2-31-0
108
K-2-32-0
109
K-2-41-0
912.841
940.226
958.483
976.740
110
K-2-42-0

260.810
268.634
273.850
279.067
111
K-2-51-0
604.904
623.051
635.149
647.247
112
K-2-52-0
329.860
339.756
346.353
352.950
113
K-2-53-0
191.760
197.513
201.348
205.183
114
K-3-10-0

GASTROINTESTINAL
364.906
375.853
383.151
390.450
115
K-3-11-0
219.380
225.961
230.349
234.736
116
K-3-12-0
222.479
229.153
233.603
238.052
117
K-3-13-0
191.760
197.513
201.348
205.183
513.921
529.338
539.617
549.895
248.179
255.625
260.588
265.552
328.854
338.719
345.296
351.873
1.130.610
1.164.529
1.187.141
1.209.753
724.713
746.455
760.949
775.443
327.099
336.912
343.454
349.996
329.860
339.756
346.353
352.950

GASTROINTESTINAL
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
118
K-3-14-0
119
K-3-15-0
120
K-3-16-0
121
L-2-21-0
122
L-2-22-0
123
L-2-31-0
124
L-2-32-0
125
L-2-41-0
987.727
1.017.359
1.037.113
1.056.868
126
L-2-42-0

221.531
228.177
232.608
237.038
127
L-2-51-0
1.478.782
1.523.145
1.552.721
1.582.297
L-2-52-0

1.131.317
1.165.256
1.187.883
1.210.509
128
- 274 No
Kode
INA-CBG
129
L-2-53-0
130
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

191.760
197.513
201.348
205.183
L-3-10-0
260.810
268.634
273.850
279.067
131
L-3-11-0
253.264
260.862
265.928
270.993
132
L-3-12-0
192.885
198.672
202.529
206.387
133
M-2-10-0
1.512.902
1.558.289
1.588.547
1.618.805
134
M-2-21-0
1.354.908
1.395.555
1.422.653
1.449.752
135
M-2-22-0
329.860
339.756
346.353
352.950
136
M-2-31-0
PROSEDUR BUNION
822.971
847.660
864.119
880.578
137
M-2-32-0
260.810
268.634
273.850
279.067
138
M-2-41-0

TULANG
260.810
268.634
273.850
279.067
139
M-2-42-0
89.882
92.579
94.376
96.174
140
M-2-51-0
191.760
197.513
201.348
205.183
141
M-2-52-0
191.760
197.513
201.348
205.183
142
M-2-61-0
PROSEDUR ARTROSKOPI
939.915
968.113
986.911
1.005.709
143
M-2-62-0
191.760
197.513
201.348
205.183
945.000
973.350
992.250
1.011.150
1.288.785
1.327.448
1.353.224
1.379.000
191.760
197.513
201.348
205.183
951.462
980.006
999.035
1.018.064
918.201
945.747
964.111
982.475

DAN WAJAH
PAHA
PAHA

TULANG
WAJAH
WAJAH
BAWAH
BAWAH
144
M-2-63-0
145
M-2-64-0
146
M-2-65-0
147
M-2-71-0
148
M-2-72-0
149
M-2-81-0
1.369.234
1.410.311
1.437.695
1.465.080
150
M-2-82-0
994.660
1.024.500
1.044.393
1.064.287
151
M-2-83-0
191.760
197.513
201.348
205.183
152
M-2-84-0
191.760
197.513
201.348
205.183
153
M-3-10-0
547.320
563.739
574.686
585.632
154
M-3-11-0
303.455
312.559
318.628
324.697
155
M-3-12-0
686.241
706.828
720.553
734.278
156
M-3-13-0
223.733
230.445
234.920
239.394
157
M-3-14-0

TERTUTUP
382.398
393.870
401.517
409.165
158
M-3-15-0
168.470
173.524
176.893
180.262
159
M-3-16-0

191.760
197.513
201.348
205.183
160
M-3-17-0
209.354
215.634
219.822
224.009
161
N-2-11-0
2.533.336
2.609.336
2.660.002
2.710.669

PERGELANGAN TANGAN
PERGELANGAN TANGAN
MUSKULOSKELETAL
SKELETAL
- 275 No
Kode
INA-CBG
162
N-2-12-0
163
N-2-21-0
164
N-2-22-0
165
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.465.510
1.509.475
1.538.785
1.568.095
1.457.785
1.501.518
1.530.674
1.559.830
329.860
339.756
346.353
352.950
N-2-23-0
329.860
339.756
346.353
352.950
166
N-2-24-0
1.065.997
1.097.977
1.119.297
1.140.617
167
N-2-31-0
897.397
924.319
942.267
960.214
168
N-2-32-0
329.860
339.756
346.353
352.950
169
N-2-41-0
329.860
339.756
346.353
352.950
170
N-2-42-0
557.857
574.592
585.749
596.907
171
N-3-10-0
329.860
339.756
346.353
352.950
172
N-3-11-0
382.190
393.656
401.300
408.943
173
N-3-12-0
295.335
304.195
310.102
316.008
174
N-3-13-0
329.860
339.756
346.353
352.950
175
N-3-14-0
283.827
292.341
298.018
303.695
176
N-3-15-0
727.803
749.637
764.193
778.749
177
O-7-10-0
121.512
125.157
127.587
130.018
178
O-7-11-0
669.197
689.273
702.657
716.041
179
O-7-12-0
243.677
250.988
255.861
260.735
180
O-7-13-0
135.425
139.488
142.196
144.905
181
P-9-10-0
180.623
186.042
189.654
193.267
182
P-9-11-0
180.623
186.042
189.654
193.267
183
P-9-12-0
180.623
186.042
189.654
193.267
184
P-9-13-0
180.623
186.042
189.654
193.267
185
P-9-14-0
180.623
186.042
189.654
193.267
186
P-9-15-0
115.133
118.587
120.890
123.192
187
P-9-16-0
180.623
186.042
189.654
193.267
188
P-9-17-0
179.846
185.242
188.839
192.436
189
Q-5-10-0
433.775
446.788
455.464
464.139
190
Q-5-11-0
325.103
334.856
341.358
347.860
191
Q-5-12-0
GIGI
286.537
295.133
300.864
306.594
192
Q-5-13-0
MEDICAL CHECK-UP
217.755
224.288
228.643
232.998
193
Q-5-14-0
239.602
246.790
251.582
256.374


DAN URETHRA
URETHRA
TRANSURETHRA
TRANSURETHRA
SALURAN KEMIH
KEMIH
KEMIH
PROSEDUR DIALISIS
CAESAR
VAGINAL/JALAN LAHIR

ASPIRASI
- 276 No
Kode
INA-CBG
194
Q-5-15-0
195
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
164.774
169.718
173.013
176.309
Q-5-16-0
VAKSINASI
186.233
191.820
195.545
199.269
196
Q-5-17-0
PASANG INFUS
161.087
165.919
169.141
172.363
197
Q-5-18-0
303.216
312.312
318.376
324.441
198
Q-5-19-0
338.977
349.146
355.926
362.705
199
Q-5-20-0
ABORSI MENGANCAM
227.205
234.021
238.565
243.109
200
Q-5-21-0
ABORSI
224.111
230.834
235.316
239.798
201
Q-5-22-0
239.602
246.790
251.582
256.374
202
Q-5-23-0
293.336
302.136
308.003
313.870
203
Q-5-24-0
200.344
206.355
210.362
214.369
204
Q-5-25-0
312.433
321.806
328.055
334.304
205
Q-5-26-0
BRONKIAL AKUT
442.228
455.494
464.339
473.184
206
Q-5-27-0
314.711
324.152
330.446
336.741
207
Q-5-28-0
255.380
263.041
268.149
273.256
208
Q-5-29-0

JANTUNG LAIN-LAIN
723.022
744.712
759.173
773.633
209
Q-5-30-0
837.904
863.041
879.799
896.557
210
Q-5-31-0
FRAKTUR
298.931
307.899
313.877
319.856
211
Q-5-32-0
SALURAN KEMIH AKUT
346.229
356.616
363.541
370.465
212
Q-5-33-0
HEMATOLOGI AKUT
362.501
373.376
380.626
387.876
213
Q-5-34-0
INFEKSI VIRUS HIV
514.957
530.406
540.705
551.004
214
Q-5-35-0
INFEKSI AKUT
583.948
601.466
613.145
624.824
215
Q-5-36-0
680.045
700.446
714.047
727.648
216
Q-5-37-0

SHOCK
346.858
357.263
364.201
371.138
217
Q-5-38-0
PARU AKUT
462.546
476.422
485.673
494.924
218
Q-5-39-0
295.995
304.875
310.795
316.715
219
Q-5-40-0
290.419
299.131
304.940
310.748
220
Q-5-41-0
402.044
414.105
422.146
430.187
221
Q-5-42-0
315.218
324.675
330.979
337.284
222
Q-5-43-0
453.933
467.550
476.629
485.708
223
Q-5-44-0
370.472
381.586
388.996
396.405
224
T-2-10-0

TERAPI DETOKSIKASI
2.282.211
2.350.677
2.396.322
2.441.966
225
U-2-10-0
1.391.785
1.433.539
1.461.375
1.489.210
226
U-2-11-0

LEHER
1.654.292
1.703.920
1.737.006
1.770.092
227
U-2-12-0
182.015
187.476
191.116
194.756
- 277 No
Kode
INA-CBG
228
U-2-13-0
229
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
238.627
245.785
250.558
255.330
U-2-14-0
443.260
456.558
465.423
474.288
230
U-2-15-0
251.851
259.406
264.443
269.480
231
U-2-21-0
293.367
302.168
308.035
313.902
232
U-2-22-0
566.808
583.812
595.148
606.484
233
U-2-23-0
742.701
764.982
779.836
794.690
234
U-2-24-0
625.936
644.714
657.233
669.751
235
U-2-25-0
238.627
245.785
250.558
255.330
236
U-2-31-0
191.760
197.513
201.348
205.183
237
U-2-32-0
238.627
245.785
250.558
255.330
238
U-3-10-0
228.140
234.984
239.546
244.109
239
U-3-11-0
242.213
249.479
254.324
259.168
240
U-3-12-0
107.106
110.319
112.462
114.604
241
U-3-13-0
235.428
242.491
247.199
251.908
242
U-3-14-0
216.310
222.799
227.125
231.451
243
U-3-15-0
188.641
194.301
198.073
201.846
244
U-3-16-0
PROSEDUR PADA GIGI
212.753
219.136
223.391
227.646
245
V-2-10-0

PROSTAT
2.075.654
2.137.923
2.179.436
2.220.949
246
V-2-11-0
234.081
241.103
245.785
250.467
746.986
769.395
784.335
799.275
329.860
339.756
346.353
352.950
329.860
339.756
346.353
352.950

(RHINOPLASTY)

RONGGA HIDUNG
TENGGOROKAN
PROSEDUR PADA PENIS

SKROTUM
SKROTUM
TRANSURETHRAL
247
V-2-12-0
248
V-2-13-0
249
V-2-14-0
250
V-2-15-0
SIRKUMSISI/SUNAT
180.623
186.042
189.654
193.267
251
V-3-10-0
376.702
388.003
395.537
403.071
252
V-3-11-0
796.919
820.827
836.765
852.704
253
V-3-12-0
460.083
473.885
483.087
492.288
254
W-2-10-0
168.470
173.524
176.893
180.262
255
W-2-11-0
430.545
443.462
452.073
460.684
256
W-2-12-0
796.919
820.827
836.765
852.704
257
W-2-13-0
127.812
131.646
134.202
136.758
258
W-2-21-0
1.602.020
1.650.081
1.682.121
1.714.162
259
W-2-22-0
168.470
173.524
176.893
180.262

PROSEDUR ABORSI
RAHIM & LEHER RAHIM
TERHALANG/TERGANGGU
TERHALANG/TERGANGGU
PANGGUL TERBUKA
PANGGUL TERBUKA
- 278 No
Kode
INA-CBG
260
W-2-23-0
Deskripsi (INA-CBG)
JALAN LAHIR
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
562.191
579.057
590.301
601.545
1.845.502
1.900.867
1.937.777
1.974.688
1.294.335
1.333.165
1.359.051
1.384.938
261
W-2-31-0
262
W-2-32-0
263
W-2-33-0
550.109
566.613
577.615
588.617
264
W-2-34-0
187.102
192.715
196.457
200.199
265
W-3-10-0
454.730
468.372
477.466
486.561
266
W-3-11-0
363.498
374.403
381.673
388.943
267
W-3-12-0
168.470
173.524
176.893
180.262
268
Z-3-10-0
1.907.300
1.964.519
2.002.665
2.040.811
269
Z-3-11-0

EMPEDU
1.457.785
1.501.518
1.530.674
1.559.830
270
Z-3-12-0
448.526
461.982
470.952
479.923
271
Z-3-13-0

LAIN-LAIN
1.485.384
1.529.945
1.559.653
1.589.361
272
Z-3-14-0
DIAGNOSTIK TIDUR
541.195
557.431
568.255
579.079
273
Z-3-15-0
191.760
197.513
201.348
205.183
274
Z-3-16-0

(MRI)
615.491
633.956
646.265
658.575
275
Z-3-17-0
PENGOBATAN NUKLIR
258.396
266.148
271.316
276.484
276
Z-3-18-0
CT-SCAN KEPALA
248.960
256.429
261.408
266.387
277
Z-3-19-0
CT SCAN LAIN-LAIN
259.119
266.892
272.075
277.257
278
Z-3-20-0
176.233
181.520
185.045
188.569
279
Z-3-21-0
168.470
173.524
176.893
180.262
280
Z-3-22-0
189.934
195.632
199.431
203.230
281
Z-3-23-0
197.833
203.768
207.725
211.681
282
Z-3-24-0
388.703
400.364
408.138
415.912
283
Z-3-25-0
173.128
178.321
181.784
185.247
284
Z-3-26-0
195.668
201.538
205.452
209.365
285
Z-3-27-0
PERAWATAN LUKA
186.810
192.415
196.151
199.887
286
Z-3-28-0
IMAGING PAYUDARA
191.760
197.513
201.348
205.183
287
Z-3-29-0
IMAGING LAIN-LAIN
552.686
569.267
580.321
591.375
288
Z-3-30-0
FOTOTERAPI
93.273
96.071
97.937
99.802
- 279 2. RUMAH SAKIT KUSTAKELAS B PENDIDIKAN

a. RawatInap
No
Kode
INA-CBG
A-4-10-i
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
SEPTIKEMIA RINGAN
2.736.833
2.818.938
2.873.675
2.928.411
A-4-10-ii
SEPTIKEMIA SEDANG
3.132.938
3.226.926
3.289.585
3.352.244
A-4-10-iii
SEPTIKEMIA BERAT
4.911.856
5.059.212
5.157.449
5.255.686
A-4-11-i
4.918.728
5.066.290
5.164.664
5.263.039
A-4-11-ii
7.598.866
7.826.832
7.978.809
8.130.787
A-4-11-iii
12.430.084
12.802.987
13.051.589
13.300.190
A-4-12-i
DEMAM RINGAN
1.929.531
1.987.417
2.026.008
2.064.598
A-4-12-ii
DEMAM SEDANG
2.767.495
2.850.520
2.905.870
2.961.219
A-4-12-iii
DEMAM BERAT
3.167.195
3.262.211
3.325.555
3.388.898
10
A-4-13-i
2.411.914
2.484.271
2.532.510
2.580.748
11
A-4-13-ii
2.894.297
2.981.126
3.039.012
3.096.897
12
A-4-13-iii
3.517.676
3.623.206
3.693.559
3.763.913
199.546
205.532
209.523
213.514
256.779
264.482
269.618
274.753
293.396
302.198
308.065
313.933

LAIN-LAIN RINGAN
LAIN-LAIN SEDANG
LAIN-LAIN BERAT
Regional 4
13
A-4-14-i
14
A-4-14-ii
15
A-4-14-iii
16
A-4-15-i
INFEKSI HIV RINGAN
2.894.297
2.981.126
3.039.012
3.096.897
17
A-4-15-ii
INFEKSI HIV SEDANG
4.341.445
4.471.688
4.558.517
4.645.346
18
A-4-15-iii
INFEKSI HIV BERAT
6.037.927
6.219.065
6.339.824
6.460.582
19
B-1-01-i
32.087.791
33.050.425
33.692.181
34.333.937
20
B-1-01-ii
35.401.413
36.463.455
37.171.483
37.879.512
21
B-1-01-iii
62.101.363
63.964.404
65.206.431
66.448.458
22
B-1-10-i
4.160.073
4.284.875
4.368.077
4.451.278
23
B-1-10-ii
10.601.870
10.919.927
11.131.964
11.344.001
24
B-1-10-iii
18.453.662
19.007.272
19.376.345
19.745.418
2.843.954
2.929.272
2.986.151
3.043.030
7.138.592
7.352.750
7.495.521
7.638.293
8.950.023
9.218.523
9.397.524
9.576.524
6.066.256
6.248.243
6.369.568
6.490.893
13.001.469
13.391.514
13.651.543
13.911.572
15.823.278
16.297.977
16.614.442
16.930.908
25
B-1-11-i
26
B-1-11-ii
27
B-1-11-iii
28
B-1-12-i
29
B-1-12-ii
30
B-1-12-iii

(RINGAN)
(SEDANG)
(BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT
- 280 No
Kode
INA-CBG
31
B-1-13-i
32
B-1-13-ii
33
B-1-13-iii
34
B-1-14-i
35
B-1-14-ii
36
B-1-14-iii
37
B-4-10-i
38
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
3.975.082
4.094.335
4.173.836
4.253.338
6.474.832
6.669.077
6.798.574
6.928.070
9.545.719
9.832.091
10.023.005
10.213.920
5.397.882
5.559.818
5.667.776
5.775.734
6.003.534
6.183.640
6.303.711
6.423.781
9.391.815
9.673.570
9.861.406
10.049.242
1.509.610
1.554.898
1.585.090
1.615.282
B-4-10-ii
2.411.914
2.484.271
2.532.510
2.580.748
39
B-4-10-iii
3.687.530
3.798.156
3.871.907
3.945.657
40
B-4-11-i
3.646.298
3.755.687
3.828.613
3.901.539
41
B-4-11-ii
5.543.284
5.709.582
5.820.448
5.931.313
42
B-4-11-iii
5.970.309
6.149.418
6.268.824
6.388.231
43
B-4-12-i
3.199.377
3.295.358
3.359.346
3.423.333
44
B-4-12-ii
4.535.929
4.672.007
4.762.725
4.853.444
45
B-4-12-iii
8.815.985
9.080.465
9.256.785
9.433.104
46
B-4-13-i
2.894.297
2.981.126
3.039.012
3.096.897
47
B-4-13-ii
4.516.709
4.652.210
4.742.544
4.832.878
48
B-4-13-iii
6.855.406
7.061.068
7.198.176
7.335.284
49
B-4-14-i
2.894.297
2.981.126
3.039.012
3.096.897
50
B-4-14-ii
3.376.680
3.477.980
3.545.513
3.613.047
51
B-4-14-iii
4.504.830
4.639.975
4.730.072
4.820.168
52
C-4-10-i
2.818.461
2.903.015
2.959.384
3.015.753
53
C-4-10-ii
5.475.974
5.640.253
5.749.772
5.859.292
54
C-4-10-iii
LEUKEMIA AKUT BERAT
9.165.273
9.440.231
9.623.537
9.806.842
55
C-4-11-i
2.894.297
2.981.126
3.039.012
3.096.897
56
C-4-11-ii
3.859.062
3.974.834
4.052.015
4.129.197
57
C-4-11-iii
6.560.858
6.757.683
6.888.901
7.020.118
58
C-4-12-i
RADIOTERAPI RINGAN
1.929.531
1.987.417
2.026.008
2.064.598
59
C-4-12-ii
RADIOTERAPI SEDANG
5.312.582
5.471.959
5.578.211
5.684.463
60
C-4-12-iii
RADIOTERAPI BERAT
10.785.606
11.109.174
11.324.886
11.540.598
61
C-4-13-i
KEMOTERAPI RINGAN
1.929.531
1.987.417
2.026.008
2.064.598
62
C-4-13-ii
KEMOTERAPI SEDANG
3.859.062
3.974.834
4.052.015
4.129.197
63
C-4-13-iii
KEMOTERAPI BERAT
5.049.298
5.200.776
5.301.762
5.402.748

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT

PANCREAS RINGAN
PANCREAS SEDANG
PANCREAS BERAT
(RINGAN)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT
Regional 4
- 281 No
Kode
INA-CBG
64
C-4-14-i
65
C-4-14-ii
66
C-4-14-iii
67
D-1-10-i
68
D-1-10-ii
69
D-1-10-iii
70
D-1-11-i
71
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
2.502.086
2.577.148
2.627.190
2.677.232
3.656.208
3.765.894
3.839.018
3.912.142
5.573.783
5.740.996
5.852.472
5.963.947
20.532.500
21.148.475
21.559.125
21.969.775
31.272.572
32.210.749
32.836.201
33.461.652
42.382.880
43.654.367
44.502.024
45.349.682
4.220.279
4.346.887
4.431.293
4.515.698
D-1-11-ii
11.007.262
11.337.480
11.557.625
11.777.770
72
D-1-11-iii
15.595.481
16.063.345
16.375.255
16.687.165
73
D-1-20-i
5.198.494
5.354.448
5.458.418
5.562.388
74
D-1-20-ii
11.696.611
12.047.509
12.281.441
12.515.373
75
D-1-20-iii
21.143.560
21.777.867
22.200.738
22.623.609
76
D-4-10-i
1.853.433
1.909.036
1.946.105
1.983.174
77
D-4-10-ii
3.742.430
3.854.703
3.929.552
4.004.400
78
D-4-10-iii
4.823.828
4.968.543
5.065.019
5.161.496
79
D-4-11-i
4.220.849
4.347.475
4.431.892
4.516.309
80
D-4-11-ii
7.543.794
7.770.107
7.920.983
8.071.859
81
D-4-11-iii
10.327.905
10.637.742
10.844.300
11.050.859
82
D-4-12-i
2.474.164
2.548.388
2.597.872
2.647.355
83
D-4-12-ii
3.431.908
3.534.865
3.603.503
3.672.142
84
D-4-12-iii
5.269.697
5.427.787
5.533.181
5.638.575
85
D-4-13-i
1.929.531
1.987.417
2.026.008
2.064.598
86
D-4-13-ii
2.894.297
2.981.126
3.039.012
3.096.897
87
D-4-13-iii
3.376.680
3.477.980
3.545.513
3.613.047
88
D-4-14-i
2.324.850
2.394.595
2.441.092
2.487.589
89
D-4-14-ii
5.427.955
5.590.794
5.699.353
5.807.912
90
D-4-14-iii
6.474.800
6.669.044
6.798.540
6.928.036
91
E-1-01-i
4.625.290
4.764.049
4.856.555
4.949.060
92
E-1-01-ii
6.058.690
6.240.451
6.361.625
6.482.798
93
E-1-01-iii
13.732.161
14.144.126
14.418.769
14.693.413
94
E-1-10-i
4.712.923
4.854.311
4.948.569
5.042.828
95
E-1-10-ii
5.720.382
5.891.994
6.006.401
6.120.809
96
E-1-10-iii
12.056.882
12.418.588
12.659.726
12.900.864

RINGAN
SEDANG
BERAT
TULANG RINGAN
TULANG SEDANG
TULANG BERAT


RINGAN
SEDANG
BERAT
Regional 4
- 282 No
Kode
INA-CBG
97
E-1-20-i
98
E-1-20-ii
99
E-1-20-iii
100
E-4-10-i
101
E-4-10-ii
102
E-4-10-iii
103
E-4-11-i
104
E-4-11-ii
105
E-4-11-iii
106
E-4-12-i
107
E-4-12-ii
108
E-4-12-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
5.457.662
5.621.392
5.730.546
5.839.699
7.309.657
7.528.947
7.675.140
7.821.333
16.196.134
16.682.018
17.005.941
17.329.864
2.411.914
2.484.271
2.532.510
2.580.748
3.430.249
3.533.157
3.601.762
3.670.367
6.556.854
6.753.560
6.884.697
7.015.834
2.057.867
2.119.603
2.160.760
2.201.918
3.893.131
4.009.925
4.087.788
4.165.650
6.419.952
6.612.551
6.740.950
6.869.349
2.458.864
2.532.629
2.581.807
2.630.984
4.271.509
4.399.655
4.485.085
4.570.515
6.975.048
7.184.299
7.323.800
7.463.301
2.593.620
2.671.428
2.723.301
2.775.173
4.453.263
4.586.861
4.675.926
4.764.992
7.705.270
7.936.428
8.090.534
8.244.639

RINGAN
SEDANG
BERAT

RINGAN
SEDANG
BERAT
Regional 4
109
E-4-13-i
110
E-4-13-ii
111
E-4-13-iii
112
F-4-10-i
SCHIZOFRENIA RINGAN
3.171.191
3.266.326
3.329.750
3.393.174
113
F-4-10-ii
SCHIZOFRENIA SEDANG
3.521.709
3.627.361
3.697.795
3.768.229
114
F-4-10-iii
SCHIZOFRENIA BERAT
5.213.968
5.370.387
5.474.667
5.578.946
115
F-4-11-i
2.923.070
3.010.762
3.069.223
3.127.685
116
F-4-11-ii
3.405.654
3.507.823
3.575.936
3.644.050
117
F-4-11-iii
DEPRESI MAYOR BERAT
4.367.293
4.498.312
4.585.657
4.673.003
1.447.148
1.490.563
1.519.506
1.548.449
2.066.323
2.128.312
2.169.639
2.210.965
4.482.540
4.617.016
4.706.667
4.796.318

IMPULSE RINGAN
IMPULSE SEDANG
IMPULSE BERAT
118
F-4-12-i
119
F-4-12-ii
120
F-4-12-iii
121
F-4-13-i
2.362.284
2.433.153
2.480.399
2.527.644
122
F-4-13-ii
3.128.272
3.222.120
3.284.685
3.347.251
123
F-4-13-iii
4.033.507
4.154.512
4.235.182
4.315.852
124
F-4-14-i
DEPRESI RINGAN
1.653.599
1.703.207
1.736.279
1.769.351
125
F-4-14-ii
DEPRESI SEDANG
2.121.076
2.184.709
2.227.130
2.269.552
126
F-4-14-iii
DEPRESI BERAT
2.854.003
2.939.623
2.996.703
3.053.783
127
F-4-15-i
1.966.035
2.025.016
2.064.337
2.103.658
128
F-4-15-ii
2.894.297
2.981.126
3.039.012
3.096.897
129
F-4-15-iii
3.811.966
3.926.325
4.002.565
4.078.804
- 283 No
Kode
INA-CBG
130
F-4-16-i
131
F-4-16-ii
132
F-4-16-iii
133
F-4-17-i
134
F-4-17-ii
135
F-4-17-iii
136
F-4-18-i
137
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
4.234.455
4.361.489
4.446.178
4.530.867
4.922.448
5.070.122
5.168.571
5.267.020
6.570.647
6.767.766
6.899.179
7.030.592
977.686
1.007.016
1.026.570
1.046.124
2.865.503
2.951.468
3.008.779
3.066.089
3.057.281
3.149.000
3.210.145
3.271.291
3.670.283
3.780.392
3.853.797
3.927.203
F-4-18-ii
4.038.348
4.159.499
4.240.265
4.321.032
138
F-4-18-iii
6.225.466
6.412.230
6.536.739
6.661.248
139
F-4-19-i
2.814.761
2.899.204
2.955.499
3.011.794
140
F-4-19-ii
3.604.374
3.712.505
3.784.592
3.856.680
141
F-4-19-iii
4.487.493
4.622.118
4.711.868
4.801.618
142
G-1-01-i
8.948.725
9.217.187
9.396.162
9.575.136
143
G-1-01-ii
15.146.796
15.601.200
15.904.136
16.207.072
144
G-1-01-iii
29.322.505
30.202.181
30.788.631
31.375.081
145
G-1-10-i
4.465.865
4.599.841
4.689.159
4.778.476
146
G-1-10-ii
6.304.692
6.493.832
6.619.926
6.746.020
147
G-1-10-iii
7.472.406
7.696.578
7.846.027
7.995.475
148
G-1-11-i
5.151.509
5.306.054
5.409.084
5.512.115
149
G-1-11-ii
10.579.012
10.896.382
11.107.962
11.319.543
150
G-1-11-iii
22.151.489
22.816.034
23.259.063
23.702.093
151
G-1-12-i
4.006.356
4.126.547
4.206.674
4.286.801
152
G-1-12-ii
9.172.154
9.447.318
9.630.761
9.814.204
153
G-1-12-iii
16.177.668
16.662.998
16.986.551
17.310.104
154
G-1-13-i
1.056.601
1.088.299
1.109.431
1.130.563
155
G-1-13-ii
2.837.914
2.923.052
2.979.810
3.036.568
156
G-1-13-iii
6.403.530
6.595.636
6.723.706
6.851.777
5.048.350
5.199.800
5.300.767
5.401.734
6.820.486
7.025.100
7.161.510
7.297.920
16.699.157
17.200.132
17.534.115
17.868.098

RINGAN
SEDANG
BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

RINGAN
SEDANG
BERAT
Regional 4
157
G-1-20-i
158
G-1-20-ii
159
G-1-20-iii
160
G-1-30-i
6.438.715
6.631.877
6.760.651
6.889.426
161
G-1-30-ii
16.805.665
17.309.835
17.645.948
17.982.061
162
G-1-30-iii
21.634.084
22.283.106
22.715.788
23.148.470
- 284 No
Kode
INA-CBG
163
G-4-10-i
164
G-4-10-ii
165
G-4-10-iii
166
G-4-11-i
167
G-4-11-ii
168
G-4-11-iii
169
G-4-12-i
170
G-4-12-ii
171
G-4-12-iii
172
G-4-13-i
173
G-4-13-ii
174
G-4-13-iii
175
G-4-14-i
176
G-4-14-ii
177
G-4-14-iii
178
G-4-15-i
179
G-4-15-ii
180
G-4-15-iii
181
G-4-16-i
182
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
2.894.297
2.981.126
3.039.012
3.096.897
3.376.680
3.477.980
3.545.513
3.613.047
5.158.630
5.313.389
5.416.561
5.519.734
4.775.382
4.918.644
5.014.151
5.109.659
5.539.443
5.705.627
5.816.415
5.927.204
8.118.150
8.361.694
8.524.057
8.686.420
3.571.566
3.678.713
3.750.144
3.821.575
4.500.173
4.635.178
4.725.181
4.815.185
6.535.965
6.732.044
6.862.763
6.993.483
1.987.195
2.046.811
2.086.555
2.126.299
3.376.680
3.477.980
3.545.513
3.613.047
3.991.715
4.111.466
4.191.300
4.271.135
3.634.284
3.743.312
3.815.998
3.888.684
5.979.623
6.159.012
6.278.604
6.398.197
7.486.624
7.711.223
7.860.956
8.010.688
3.719.795
3.831.389
3.905.785
3.980.181
4.494.815
4.629.659
4.719.555
4.809.452
5.554.365
5.720.996
5.832.083
5.943.170
2.411.914
2.484.271
2.532.510
2.580.748
G-4-16-ii
3.607.039
3.715.250
3.787.391
3.859.532
183
G-4-16-iii
6.546.132
6.742.516
6.873.438
7.004.361
184
G-4-17-i
3.446.846
3.550.251
3.619.188
3.688.125
185
G-4-17-ii
4.277.687
4.406.018
4.491.571
4.577.125
186
G-4-17-iii
7.169.439
7.384.522
7.527.911
7.671.299
187
G-4-18-i
2.894.297
2.981.126
3.039.012
3.096.897
188
G-4-18-ii
4.149.921
4.274.418
4.357.417
4.440.415
189
G-4-18-iii
4.396.418
4.528.311
4.616.239
4.704.167
190
G-4-19-i
2.411.914
2.484.271
2.532.510
2.580.748
191
G-4-19-ii
4.888.068
5.034.710
5.132.471
5.230.233
192
G-4-19-iii
7.291.446
7.510.189
7.656.018
7.801.847

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
DEGENERATIF RINGAN
DEGENERATIF SEDANG
DEGENERATIF BERAT
RINGAN
SEDANG
BERAT
TRAUMATIK RINGAN
TRAUMATIK SEDANG
TRAUMATIK BERAT
DENGAN INFARK BERAT
TANPA INFARK RINGAN
TANPA INFARK SEDANG
TANPA INFARK BERAT

PERIFER RINGAN
PERIFER SEDANG
PERIFER BERAT
PERSARAFAN RINGAN
PERSARAFAN SEDANG
PERSARAFAN BERAT
SEDANG
Regional 4
- 285 No
Kode
INA-CBG
193
G-4-20-i
194
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
1.688.340
1.738.990
1.772.757
1.806.524
G-4-20-ii
2.397.444
2.469.368
2.517.317
2.565.265
195
G-4-20-iii
4.088.204
4.210.850
4.292.614
4.374.378
196
G-4-21-i
1.956.400
2.015.092
2.054.220
2.093.348
197
G-4-21-ii
4.051.899
4.173.456
4.254.494
4.335.532
198
G-4-21-iii
4.773.615
4.916.824
5.012.296
5.107.768
199
G-4-22-i
1.929.531
1.987.417
2.026.008
2.064.598
200
G-4-22-ii
2.411.914
2.484.271
2.532.510
2.580.748
201
G-4-22-iii
2.767.096
2.850.109
2.905.451
2.960.793
202
G-4-23-i
1.929.531
1.987.417
2.026.008
2.064.598
203
G-4-23-ii
2.411.914
2.484.271
2.532.510
2.580.748
204
G-4-23-iii
3.447.660
3.551.090
3.620.043
3.688.996
205
G-4-24-i
1.929.531
1.987.417
2.026.008
2.064.598
206
G-4-24-ii
2.411.914
2.484.271
2.532.510
2.580.748
207
G-4-24-iii
TRAUMA KEPALA BERAT
5.068.376
5.220.427
5.321.795
5.423.162
208
G-4-25-i
GEGAR OTAK RINGAN
1.833.431
1.888.434
1.925.103
1.961.772
209
G-4-25-ii
GEGAR OTAK SEDANG
2.308.330
2.377.580
2.423.747
2.469.913
210
G-4-25-iii
GEGAR OTAK BERAT
3.011.733
3.102.085
3.162.319
3.222.554
211
G-4-26-i
2.894.297
2.981.126
3.039.012
3.096.897
212
G-4-26-ii
3.376.680
3.477.980
3.545.513
3.613.047
213
G-4-26-iii
6.445.609
6.638.977
6.767.889
6.896.801
214
H-1-20-i
2.773.492
2.856.697
2.912.167
2.967.636
215
H-1-20-ii
5.057.777
5.209.510
5.310.665
5.411.821
216
H-1-20-iii
6.878.260
7.084.608
7.222.173
7.359.738
217
H-1-30-i
2.715.513
2.796.978
2.851.288
2.905.599
218
H-1-30-ii
3.095.685
3.188.555
3.250.469
3.312.382
219
H-1-30-iii
5.165.038
5.319.989
5.423.290
5.526.590
220
H-4-10-i
2.894.297
2.981.126
3.039.012
3.096.897
221
H-4-10-ii
4.823.828
4.968.543
5.065.019
5.161.496
222
H-4-10-iii
7.864.264
8.100.192
8.257.477
8.414.763
223
H-4-11-i
1.970.698
2.029.819
2.069.233
2.108.647
224
H-4-11-ii
2.201.962
2.268.020
2.312.060
2.356.099
225
H-4-11-iii
3.148.599
3.243.057
3.306.029
3.369.001
226
H-4-12-i
2.734.265
2.816.293
2.870.978
2.925.663

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)

RINGAN
SEDANG
Regional 4
- 286 No
Kode
INA-CBG
227
H-4-12-ii
228
H-4-12-iii
229
I-1-01-i
230
I-1-01-ii
231
I-1-01-iii
232
I-1-02-i
233
I-1-02-ii
234
I-1-02-iii
235
I-1-03-i
236
I-1-03-ii
237
I-1-03-iii
238
I-1-04-i
239
I-1-04-ii
240
I-1-04-iii
241
I-1-05-i
242
I-1-05-ii
243
I-1-05-iii
244
I-1-06-i
245
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
3.703.741
3.814.853
3.888.928
3.963.002
6.179.438
6.364.822
6.488.410
6.611.999
41.627.323
42.876.143
43.708.689
44.541.235
42.543.341
43.819.641
44.670.508
45.521.375
67.153.848
69.168.463
70.511.540
71.854.617
23.094.599
23.787.437
24.249.329
24.711.221
29.792.033
30.685.794
31.281.634
31.877.475
36.720.412
37.822.025
38.556.433
39.290.841
14.222.476
14.649.150
14.933.599
15.218.049
19.494.351
20.079.182
20.469.069
20.858.956
28.591.715
29.449.467
30.021.301
30.593.135
17.351.004
17.871.534
18.218.554
18.565.574
22.287.672
22.956.302
23.402.056
23.847.809
47.512.689
48.938.070
49.888.324
50.838.578
30.566.381
31.483.372
32.094.700
32.706.028
36.679.657
37.780.047
38.513.640
39.247.233
50.470.977
51.985.106
52.994.526
54.003.945
14.408.314
14.840.563
15.128.730
15.416.896
I-1-06-ii
21.745.566
22.397.933
22.832.844
23.267.756
246
I-1-06-iii
27.994.318
28.834.147
29.394.034
29.953.920
247
I-1-07-i
18.948.024
19.516.465
19.895.425
20.274.386
248
I-1-07-ii
23.376.237
24.077.524
24.545.049
25.012.573
249
I-1-07-iii
25.503.322
26.268.422
26.778.488
27.288.555
250
I-1-11-i
3.604.376
3.712.507
3.784.595
3.856.683
251
I-1-11-ii
4.007.706
4.127.937
4.208.091
4.288.245
252
I-1-11-iii
5.333.035
5.493.026
5.599.687
5.706.347
253
I-1-12-i
11.046.799
11.378.203
11.599.139
11.820.075
254
I-1-12-ii
15.327.949
15.787.788
16.094.347
16.400.906
255
I-1-12-iii
21.378.871
22.020.237
22.447.815
22.875.392

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
KATETERISASI RINGAN
KATETERISASI SEDANG
KATETERISASI BERAT
RINGAN
SEDANG
BERAT

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
Regional 4
- 287 No
Kode
INA-CBG
256
I-1-13-i
257
I-1-13-ii
258
I-1-13-iii
259
I-1-14-i
260
I-1-14-ii
261
I-1-14-iii
262
I-1-15-i
263
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
6.498.117
6.693.061
6.823.023
6.952.985
7.560.161
7.786.966
7.938.169
8.089.372
13.781.668
14.195.118
14.470.751
14.746.385
23.773.852
24.487.067
24.962.544
25.438.021
29.547.502
30.433.927
31.024.877
31.615.827
38.717.416
39.878.938
40.653.287
41.427.635
4.658.535
4.798.291
4.891.462
4.984.632
I-1-15-ii
13.646.046
14.055.427
14.328.348
14.601.269
264
I-1-15-iii
70.633.971
72.752.990
74.165.669
75.578.349
265
I-1-16-i
10.188.794
10.494.457
10.698.233
10.902.009
266
I-1-16-ii
26.490.863
27.285.589
27.815.407
28.345.224
267
I-1-16-iii
30.556.561
31.473.258
32.084.389
32.695.520
268
I-1-17-i
3.267.628
3.365.657
3.431.009
3.496.362
269
I-1-17-ii
6.768.442
6.971.496
7.106.864
7.242.233
270
I-1-17-iii
39.239.311
40.416.491
41.201.277
41.986.063
271
I-1-20-i
3.898.870
4.015.836
4.093.814
4.171.791
272
I-1-20-ii
7.017.966
7.228.505
7.368.864
7.509.224
273
I-1-20-iii
9.357.289
9.638.007
9.825.153
10.012.299
274
I-1-30-i
11.559.239
11.906.017
12.137.201
12.368.386
275
I-1-30-ii
24.045.553
24.766.920
25.247.831
25.728.742
276
I-1-30-iii
37.261.874
38.379.730
39.124.968
39.870.205
277
I-1-40-i
15.544.571
16.010.908
16.321.800
16.632.691
278
I-1-40-ii
21.588.070
22.235.712
22.667.474
23.099.235
279
I-1-40-iii
27.050.842
27.862.367
28.403.384
28.944.401
280
I-4-10-i
4.520.813
4.656.437
4.746.854
4.837.270
281
I-4-10-ii
7.138.445
7.352.598
7.495.367
7.638.136
282
I-4-10-iii
10.297.829
10.606.764
10.812.721
11.018.677
283
I-4-11-i
5.360.502
5.521.317
5.628.527
5.735.737
284
I-4-11-ii
6.633.642
6.832.651
6.965.324
7.097.997

KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

DARAH VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
Regional 4
- 288 No
Kode
INA-CBG
285
I-4-11-iii
286
I-4-12-i
287
288
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
11.739.972
12.092.171
12.326.970
12.561.770
4.695.243
4.836.100
4.930.005
5.023.909
I-4-12-ii
6.700.098
6.901.101
7.035.103
7.169.105
I-4-12-iii
8.128.161
8.372.006
8.534.569
8.697.132
4.217.618
4.344.147
4.428.499
4.512.852
6.127.339
6.311.159
6.433.706
6.556.253
12.541.952
12.918.211
13.169.050
13.419.889

VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
Regional 4
289
I-4-13-i
290
I-4-13-ii
291
I-4-13-iii
292
I-4-14-i
2.622.969
2.701.658
2.754.118
2.806.577
293
I-4-14-ii
3.069.262
3.161.340
3.222.725
3.284.110
294
I-4-14-iii
4.756.335
4.899.025
4.994.151
5.089.278
3.859.062
3.974.834
4.052.015
4.129.197
5.524.439
5.690.172
5.800.661
5.911.149
6.296.531
6.485.427
6.611.358
6.737.288

295
I-4-15-i
296
I-4-15-ii
297
I-4-15-iii
298
I-4-16-i
2.894.297
2.981.126
3.039.012
3.096.897
299
I-4-16-ii
4.690.658
4.831.378
4.925.191
5.019.004
300
I-4-16-iii
5.909.396
6.086.678
6.204.866
6.323.054
301
I-4-17-i
HIPERTENSI RINGAN
2.590.336
2.668.046
2.719.852
2.771.659
302
I-4-17-ii
HIPERTENSI SEDANG
3.668.173
3.778.218
3.851.582
3.924.945
303
I-4-17-iii
HIPERTENSI BERAT
4.462.508
4.596.383
4.685.633
4.774.883
3.814.820
3.929.265
4.005.561
4.081.858
5.844.049
6.019.371
6.136.252
6.253.133
7.878.715
8.115.077
8.272.651
8.430.225
2.985.597
3.075.165
3.134.877
3.194.589
4.890.314
5.037.024
5.134.830
5.232.636
5.829.210
6.004.086
6.120.671
6.237.255

RINGAN
SEDANG
KONGENITAL BERAT
RINGAN
SEDANG
BERAT
304
I-4-18-i
305
I-4-18-ii
306
I-4-18-iii
307
I-4-19-i
308
I-4-19-ii
309
I-4-19-iii
310
I-4-20-i
3.623.445
3.732.148
3.804.617
3.877.086
311
I-4-20-ii
4.174.479
4.299.713
4.383.203
4.466.693
312
I-4-20-iii
5.540.228
5.706.435
5.817.240
5.928.044
313
I-4-21-i
4.818.595
4.963.153
5.059.525
5.155.897
314
I-4-21-ii
6.010.885
6.191.211
6.311.429
6.431.647
315
I-4-21-iii
8.200.121
8.446.125
8.610.127
8.774.130
316
I-4-22-i
3.135.488
3.229.553
3.292.263
3.354.972
317
I-4-22-ii
3.613.021
3.721.411
3.793.672
3.865.932
- 289 No
Kode
INA-CBG
318
I-4-22-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.271.299
5.429.438
5.534.864
5.640.290
2.375.309
2.446.568
2.494.075
2.541.581
2.916.332
3.003.822
3.062.149
3.120.475
5.698.247
5.869.195
5.983.160
6.097.125
2.833.058
2.918.050
2.974.711
3.031.372
7.073.362
7.285.562
7.427.030
7.568.497
8.942.988
9.211.278
9.390.137
9.568.997
23.266.717
23.964.719
24.430.053
24.895.388
25.342.657
26.102.936
26.609.789
27.116.642
41.660.116
42.909.919
43.743.121
44.576.324
11.667.726
12.017.758
12.251.113
12.484.467
12.499.244
12.874.221
13.124.206
13.374.191
18.470.321
19.024.430
19.393.837
19.763.243
4.552.916
4.689.503
4.780.561
4.871.620
10.996.946
11.326.854
11.546.793
11.766.732
19.471.444
20.055.587
20.445.016
20.834.445
3.935.176
4.053.231
4.131.935
4.210.638
5.723.403
5.895.105
6.009.573
6.124.041
8.606.230
8.864.417
9.036.541
9.208.666
2.653.706
2.733.318
2.786.392
2.839.466
12.996.234
13.386.121
13.646.046
13.905.971
39.196.071
40.371.954
41.155.875
41.939.796
319
I-4-23-i
320
I-4-23-ii
321
I-4-23-iii
322
I-4-24-i
323
I-4-24-ii
324
I-4-24-iii
325
J-1-01-i
326
J-1-01-ii
327
J-1-01-iii
328
J-1-02-i
329
J-1-02-ii
330
J-1-02-iii
331
J-1-10-i
332
J-1-10-ii
333
J-1-10-iii
334
J-1-20-i
335
J-1-20-ii
336
J-1-20-iii
337
J-1-30-i
338
J-1-30-ii
339
J-1-30-iii
340
J-4-10-i
3.062.731
3.154.613
3.215.868
3.277.123
341
J-4-10-ii
4.379.338
4.510.718
4.598.305
4.685.892
342
J-4-10-iii
6.625.285
6.824.043
6.956.549
7.089.055
343
J-4-11-i
1.932.194
1.990.160
2.028.804
2.067.447
344
J-4-11-ii
2.689.570
2.770.257
2.824.048
2.877.840
345
J-4-11-iii
3.854.222
3.969.849
4.046.933
4.124.018
346
J-4-12-i
EMBOLI PARU RINGAN
2.954.826
3.043.471
3.102.568
3.161.664
347
J-4-12-ii
EMBOLI PARU SEDANG
3.826.399
3.941.191
4.017.719
4.094.247
348
J-4-12-iii
EMBOLI PARU BERAT
5.109.769
5.263.062
5.365.258
5.467.453
- 290 No
Kode
INA-CBG
349
J-4-13-i
350
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
4.551.554
4.688.101
4.779.132
4.870.163
J-4-13-ii
6.690.785
6.891.509
7.025.324
7.159.140
351
J-4-13-iii
10.878.215
11.204.562
11.422.126
11.639.690
352
J-4-14-i
TUMOR PARU RINGAN
3.101.741
3.194.793
3.256.828
3.318.862
353
J-4-14-ii
TUMOR PARU SEDANG
5.195.840
5.351.715
5.455.632
5.559.549
354
J-4-14-iii
TUMOR PARU BERAT
6.177.590
6.362.917
6.486.469
6.610.021
2.894.297
2.981.126
3.039.012
3.096.897
5.237.654
5.394.783
5.499.537
5.604.290
6.544.344
6.740.674
6.871.561
7.002.448
2.411.914
2.484.271
2.532.510
2.580.748
3.376.680
3.477.980
3.545.513
3.613.047
6.091.175
6.273.910
6.395.733
6.517.557

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
Regional 4
355
J-4-15-i
356
J-4-15-ii
357
J-4-15-iii
358
J-4-16-i
359
J-4-16-ii
360
J-4-16-iii
361
J-4-17-i
3.012.107
3.102.471
3.162.713
3.222.955
362
J-4-17-ii
4.069.875
4.191.971
4.273.369
4.354.766
363
J-4-17-iii
5.320.998
5.480.628
5.587.048
5.693.468
364
J-4-18-i
2.710.044
2.791.346
2.845.547
2.899.747
365
J-4-18-ii
3.773.467
3.886.671
3.962.140
4.037.610
366
J-4-18-iii
3.913.919
4.031.337
4.109.615
4.187.894
367
J-4-19-i
3.376.680
3.477.980
3.545.513
3.613.047
368
J-4-19-ii
3.859.062
3.974.834
4.052.015
4.129.197
369
J-4-19-iii
6.045.674
6.227.044
6.347.957
6.468.871
370
J-4-20-i
3.376.680
3.477.980
3.545.513
3.613.047
371
J-4-20-ii
4.118.925
4.242.493
4.324.871
4.407.250
372
J-4-20-iii
9.307.285
9.586.504
9.772.650
9.958.795
1.929.531
1.987.417
2.026.008
2.064.598
4.760.506
4.903.321
4.998.531
5.093.741
6.790.038
6.993.739
7.129.540
7.265.341
5.198.494
5.354.448
5.458.418
5.562.388
7.254.839
7.472.485
7.617.581
7.762.678
8.496.666
8.751.566
8.921.499
9.091.433

USUS BESAR (RINGAN)
USUS BESAR (SEDANG)
USUS BESAR (BERAT)
373
J-4-21-i
374
J-4-21-ii
375
J-4-21-iii
376
K-1-10-i
377
K-1-10-ii
378
K-1-10-iii
379
K-1-11-i
4.469.905
4.604.002
4.693.400
4.782.798
380
K-1-11-ii
5.868.446
6.044.499
6.161.868
6.279.237
381
K-1-11-iii
14.892.960
15.339.749
15.637.608
15.935.468
- 291 No
Kode
INA-CBG
382
K-1-12-i
383
K-1-12-ii
384
K-1-12-iii
385
K-1-13-i
386
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
2.404.467
2.476.601
2.524.690
2.572.779
3.133.764
3.227.777
3.290.452
3.353.127
6.233.715
6.420.727
6.545.401
6.670.076
2.731.145
2.813.079
2.867.702
2.922.325
K-1-13-ii
4.770.525
4.913.641
5.009.052
5.104.462
387
K-1-13-iii
5.101.905
5.254.962
5.357.000
5.459.038
388
K-1-14-i
4.413.691
4.546.102
4.634.376
4.722.650
389
K-1-14-ii
5.184.381
5.339.912
5.443.600
5.547.287
390
K-1-14-iii
12.765.448
13.148.412
13.403.721
13.659.030
391
K-1-20-i
8.563.856
8.820.772
8.992.049
9.163.326
392
K-1-20-ii
11.952.885
12.311.471
12.550.529
12.789.587
393
K-1-20-iii
25.531.926
26.297.884
26.808.523
27.319.161
394
K-1-30-i
5.637.156
5.806.271
5.919.014
6.031.757
395
K-1-30-ii
10.396.987
10.708.897
10.916.837
11.124.776
396
K-1-30-iii
16.191.974
16.677.733
17.001.573
17.325.412
397
K-1-40-i
5.663.204
5.833.100
5.946.364
6.059.628
398
K-1-40-ii
6.231.794
6.418.747
6.543.383
6.668.019
399
K-1-40-iii
10.334.830
10.644.874
10.851.571
11.058.268
400
K-1-50-i
4.319.658
4.449.248
4.535.641
4.622.034
401
K-1-50-ii
5.594.161
5.761.986
5.873.869
5.985.753
402
K-1-50-iii
PROSEDUR ANAL BERAT
7.942.221
8.180.488
8.339.332
8.498.177
403
K-4-10-i
3.271.830
3.369.985
3.435.422
3.500.859
404
K-4-10-ii
3.914.937
4.032.385
4.110.684
4.188.983
405
K-4-10-iii
16.211.704
16.698.056
17.022.290
17.346.524
406
K-4-11-i
1.929.531
1.987.417
2.026.008
2.064.598
407
K-4-11-ii
2.894.297
2.981.126
3.039.012
3.096.897
408
K-4-11-iii
5.259.980
5.417.779
5.522.979
5.628.179
409
K-4-12-i
1.929.531
1.987.417
2.026.008
2.064.598
410
K-4-12-ii
2.882.690
2.969.170
3.026.824
3.084.478
411
K-4-12-iii
6.918.250
7.125.797
7.264.162
7.402.527
412
K-4-13-i
2.894.297
2.981.126
3.039.012
3.096.897
413
K-4-13-ii
3.748.827
3.861.292
3.936.268
4.011.245


RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)

(RINGAN)
(SEDANG)
Regional 4
- 292 No
Kode
INA-CBG
414
K-4-13-iii
415
K-4-14-i
416
K-4-14-ii
417
K-4-14-iii
418
K-4-15-i
419
K-4-15-ii
420
K-4-15-iii
421
K-4-16-i
422
423
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
6.131.440
6.315.383
6.438.012
6.560.641
2.411.914
2.484.271
2.532.510
2.580.748
3.264.274
3.362.202
3.427.487
3.492.773
4.937.525
5.085.651
5.184.402
5.283.152
2.411.914
2.484.271
2.532.510
2.580.748
4.535.056
4.671.108
4.761.809
4.852.510
6.452.568
6.646.146
6.775.197
6.904.248
2.411.914
2.484.271
2.532.510
2.580.748
K-4-16-ii
2.894.297
2.981.126
3.039.012
3.096.897
K-4-16-iii
3.532.865
3.638.851
3.709.508
3.780.166
1.929.531
1.987.417
2.026.008
2.064.598
2.815.222
2.899.679
2.955.983
3.012.288
3.746.773
3.859.176
3.934.112
4.009.047
1.929.531
1.987.417
2.026.008
2.064.598
2.995.433
3.085.296
3.145.204
3.205.113
3.543.582
3.649.889
3.720.761
3.791.633
19.745.377
20.337.739
20.732.646
21.127.554
20.540.636
21.156.855
21.567.667
21.978.480
31.470.625
32.414.744
33.044.156
33.673.569
926.191
953.977
972.501
991.025
1.341.591
1.381.839
1.408.670
1.435.502
1.414.960
1.457.409
1.485.708
1.514.007
373.969
385.188
392.667
400.147
841.692
866.943
883.777
900.611
1.426.446
1.469.239
1.497.768
1.526.297

RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
Regional 4
424
K-4-17-i
425
K-4-17-ii
426
K-4-17-iii
427
K-4-18-i
428
K-4-18-ii
429
K-4-18-iii
430
L-1-20-i
431
L-1-20-ii
432
L-1-20-iii
433
L-1-30-i
434
L-1-30-ii
435
L-1-30-iii
436
L-1-40-i
437
L-1-40-ii
438
L-1-40-iii
439
L-1-50-i
6.498.117
6.693.061
6.823.023
6.952.985
440
L-1-50-ii
11.696.611
12.047.509
12.281.441
12.515.373
441
L-1-50-iii
14.142.857
14.567.143
14.850.000
15.132.857
442
L-4-10-i
299.318
308.298
314.284
320.271
443
L-4-10-ii
349.205
359.681
366.665
373.649
444
L-4-10-iii
706.411
727.604
741.732
755.860
445
L-4-11-i
2.737.478
2.819.602
2.874.351
2.929.101
- 293 No
Kode
INA-CBG
446
L-4-11-ii
447
L-4-11-iii
448
L-4-12-i
449
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
3.750.296
3.862.805
3.937.811
4.012.817
10.170.335
10.475.445
10.678.852
10.882.258
299.318
308.298
314.284
320.271
L-4-12-ii
439.170
452.345
461.128
469.911
450
L-4-12-iii
736.435
758.528
773.257
787.986
451
L-4-13-i
1.816.663
1.871.163
1.907.496
1.943.829
452
L-4-13-ii
2.094.719
2.157.561
2.199.455
2.241.350
453
L-4-13-iii
3.142.242
3.236.509
3.299.354
3.362.199
454
L-4-14-i
199.546
205.532
209.523
213.514
455
L-4-14-ii
299.318
308.298
314.284
320.271
456
L-4-14-iii
467.990
482.029
491.389
500.749
457
M-1-01-i
972.862
1.002.048
1.021.506
1.040.963
458
M-1-01-ii
1.085.872
1.118.448
1.140.166
1.161.883
459
M-1-01-iii
1.525.356
1.571.117
1.601.624
1.632.131
460
M-1-02-i
621.526
640.172
652.603
665.033
461
M-1-02-ii
1.020.428
1.051.041
1.071.449
1.091.858
462
M-1-02-iii
1.847.948
1.903.387
1.940.346
1.977.305
1.669.954
1.720.053
1.753.452
1.786.851
2.005.853
2.066.029
2.106.146
2.146.263
2.083.241
2.145.738
2.187.403
2.229.068
410.002
422.302
430.502
438.702
525.619
541.387
551.900
562.412
657.713
677.444
690.598
703.752
638.705
657.866
670.640
683.414
738.172
760.317
775.080
789.844
1.257.307
1.295.026
1.320.172
1.345.319
781.620
805.069
820.701
836.334
1.047.127
1.078.541
1.099.483
1.120.426
2.133.097
2.197.090
2.239.752
2.282.414
440.637
453.856
462.669
471.481
1.637.395
1.686.517
1.719.265
1.752.013
2.042.385
2.103.657
2.144.504
2.185.352
463
M-1-03-i
464
M-1-03-ii
465
M-1-03-iii
466
M-1-04-i
467
M-1-04-ii
468
M-1-04-iii
469
M-1-05-i
470
M-1-05-ii
471
M-1-05-iii
472
M-1-07-i
473
M-1-07-ii
474
M-1-07-iii
475
M-1-10-i
476
M-1-10-ii
477
M-1-10-iii


TULANG WAJAH RINGAN
TULANG WAJAH SEDANG
TULANG WAJAH BERAT
Regional 4
- 294 No
Kode
INA-CBG
478
M-1-20-i
479
M-1-20-ii
480
M-1-20-iii
481
M-1-30-i
482
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
435.904
448.981
457.699
466.417
621.689
640.339
652.773
665.207
1.209.447
1.245.731
1.269.920
1.294.108
260.736
268.558
273.772
278.987
M-1-30-ii
538.746
554.908
565.683
576.458
483
M-1-30-iii
PROSEDUR KAKI BERAT
803.695
827.806
843.880
859.954
484
M-1-40-i
292.069
300.831
306.672
312.513
485
M-1-40-ii
537.611
553.739
564.491
575.243
486
M-1-40-iii
940.819
969.043
987.860
1.006.676
487
M-1-50-i
348.910
359.378
366.356
373.334
488
M-1-50-ii
702.365
723.436
737.483
751.530
489
M-1-50-iii
1.075.221
1.107.478
1.128.982
1.150.487
263.317
271.217
276.483
281.749
527.163
542.978
553.521
564.064
917.450
944.973
963.322
981.671
352.739
363.321
370.376
377.431
719.763
741.356
755.751
770.146
1.160.344
1.195.155
1.218.362
1.241.568

SENDI MAYOR RINGAN
SENDI MAYOR SEDANG
SENDI MAYOR BERAT

RINGAN
SEDANG
BERAT

SELAIN KAKI (BERAT)
Regional 4
490
M-1-60-i
491
M-1-60-ii
492
M-1-60-iii
493
M-1-70-i
494
M-1-70-ii
495
M-1-70-iii
496
M-1-80-i
284.212
292.739
298.423
304.107
497
M-1-80-ii
429.671
442.561
451.154
459.748
498
M-1-80-iii
989.214
1.018.890
1.038.674
1.058.459
499
M-4-10-i
199.546
205.532
209.523
213.514
500
M-4-10-ii
299.318
308.298
314.284
320.271
501
M-4-10-iii
FRAKTUR FEMUR BERAT
583.156
600.651
612.314
623.977
502
M-4-11-i
249.432
256.915
261.904
266.892
503
M-4-11-ii
546.499
562.894
573.824
584.754
504
M-4-11-iii
970.023
999.123
1.018.524
1.037.924
505
M-4-12-i
199.546
205.532
209.523
213.514
506
M-4-12-ii
363.073
373.965
381.227
388.488
507
M-4-12-iii
655.898
675.575
688.693
701.811
508
M-4-13-i
332.287
342.255
348.901
355.547

PANGGUL RINGAN
PANGGUL SEDANG
PANGGUL BERAT
PELVIS RINGAN
PELVIS SEDANG
PELVIS BERAT
- 295 No
Kode
INA-CBG
509
M-4-13-ii
510
M-4-13-iii
511
M-4-14-i
512
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
498.864
513.830
523.807
533.784
988.470
1.018.124
1.037.893
1.057.662
378.325
389.675
397.242
404.808
M-4-14-ii
467.364
481.384
490.732
500.079
513
M-4-14-iii
OSTEOMIELITIS BERAT
700.060
721.062
735.063
749.064
514
M-4-15-i
224.595
231.333
235.825
240.317
515
M-4-15-ii
299.479
308.464
314.453
320.443
516
M-4-15-iii
848.069
873.511
890.472
907.434
517
M-4-16-i
249.432
256.915
261.904
266.892
518
M-4-16-ii
399.091
411.064
419.046
427.028
519
M-4-16-iii
669.376
689.457
702.844
716.232
249.432
256.915
261.904
266.892
349.205
359.681
366.665
373.649
487.683
502.313
512.067
521.821
263.728
271.639
276.914
282.189
399.091
411.064
419.046
427.028
447.267
460.685
469.630
478.575
196.085
201.968
205.889
209.811
330.270
340.178
346.784
353.389
645.042
664.393
677.294
690.195
199.546
205.532
209.523
213.514
299.318
308.298
314.284
320.271
331.715
341.667
348.301
354.935
199.546
205.532
209.523
213.514
249.432
256.915
261.904
266.892
572.682
589.862
601.316
612.769

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
RINGAN
SEDANG
BERAT
ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
Regional 4
520
M-4-17-i
521
M-4-17-ii
522
M-4-17-iii
523
M-4-18-i
524
M-4-18-ii
525
M-4-18-iii
526
M-4-19-i
527
M-4-19-ii
528
M-4-19-iii
529
M-4-20-i
530
M-4-20-ii
531
M-4-20-iii
532
M-4-21-i
533
M-4-21-ii
534
M-4-21-iii
535
N-1-01-i
5.220.789
5.377.413
5.481.829
5.586.245
536
N-1-01-ii
7.061.000
7.272.830
7.414.050
7.555.270
537
N-1-01-iii
14.971.420
15.420.563
15.719.991
16.019.419
7.202.482
7.418.556
7.562.606
7.706.656
9.741.194
10.033.430
10.228.254
10.423.078
538
N-1-11-i
539
N-1-11-ii

RINGAN
SEDANG
- 296 No
Kode
INA-CBG
540
N-1-11-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
20.654.230
21.273.857
21.686.941
22.100.026
3.898.870
4.015.836
4.093.814
4.171.791
9.070.446
9.342.559
9.523.968
9.705.377
16.531.452
17.027.396
17.358.025
17.688.654
541
N-1-12-i
542
N-1-12-ii
543
N-1-12-iii
544
N-1-20-i
5.278.762
5.437.125
5.542.700
5.648.276
545
N-1-20-ii
10.465.909
10.779.886
10.989.205
11.198.523
546
N-1-20-iii
11.972.051
12.331.213
12.570.654
12.810.095
6.280.020
6.468.420
6.594.020
6.719.621
9.543.273
9.829.571
10.020.437
10.211.302
10.985.881
11.315.457
11.535.175
11.754.892
5.658.912
5.828.680
5.941.858
6.055.036
7.670.857
7.900.983
8.054.400
8.207.817
8.921.429
9.189.072
9.367.500
9.545.929
2.411.914
2.484.271
2.532.510
2.580.748
3.229.620
3.326.509
3.391.101
3.455.694
7.069.057
7.281.129
7.422.510
7.563.891

URIN BAWAH RINGAN
URIN BAWAH SEDANG
URIN BAWAH BERAT
RINGAN
SEDANG
BERAT
GINJAL RINGAN
GINJAL SEDANG
GINJAL BERAT
547
N-1-30-i
548
N-1-30-ii
549
N-1-30-iii
550
N-1-40-i
551
N-1-40-ii
552
N-1-40-iii
553
N-4-10-i
554
N-4-10-ii
555
N-4-10-iii
556
N-4-11-i
1.847.051
1.902.463
1.939.404
1.976.345
557
N-4-11-ii
3.121.472
3.215.116
3.277.546
3.339.975
558
N-4-11-iii
3.617.871
3.726.407
3.798.764
3.871.122
559
N-4-12-i
1.929.531
1.987.417
2.026.008
2.064.598
560
N-4-12-ii
2.894.297
2.981.126
3.039.012
3.096.897
561
N-4-12-iii
4.805.484
4.949.648
5.045.758
5.141.868
562
N-4-13-i
BATU URIN RINGAN
2.545.645
2.622.014
2.672.927
2.723.840
563
N-4-13-ii
BATU URIN SEDANG
3.069.090
3.161.163
3.222.545
3.283.927
564
N-4-13-iii
BATU URIN BERAT
7.558.327
7.785.077
7.936.244
8.087.410
1.671.332
1.721.472
1.754.898
1.788.325
2.573.640
2.650.850
2.702.322
2.753.795
4.173.624
4.298.833
4.382.306
4.465.778
2.479.551
2.553.937
2.603.528
2.653.119
565
N-4-14-i
566
N-4-14-ii
567
N-4-14-iii
568
N-4-15-i

(RINGAN)
(SEDANG)
(BERAT)
SALURAN URIN RINGAN
- 297 No
Kode
INA-CBG
569
N-4-15-ii
570
N-4-15-iii
571
N-4-16-i
572
N-4-16-ii
573
N-4-16-iii
574
O-6-10-i
575
O-6-10-ii
576
O-6-10-iii
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
584
585
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
3.402.715
3.504.797
3.572.851
3.640.905
3.883.112
3.999.605
4.077.268
4.154.930
3.218.114
3.314.658
3.379.020
3.443.382
3.859.062
3.974.834
4.052.015
4.129.197
8.115.034
8.358.485
8.520.786
8.683.086
4.751.704
4.894.256
4.989.290
5.084.324
5.275.116
5.433.370
5.538.872
5.644.374
5.913.469
6.090.873
6.209.142
6.327.411
2.483.411
2.557.913
2.607.581
2.657.249
3.185.989
3.281.569
3.345.289
3.409.008
5.399.263
5.561.241
5.669.226
5.777.211
2.162.566
2.227.443
2.270.694
2.313.945
2.597.236
2.675.153
2.727.098
2.779.042
3.263.055
3.360.946
3.426.208
3.491.469
2.167.281
2.232.299
2.275.645
2.318.990
O-6-13-ii
3.194.146
3.289.971
3.353.854
3.417.737
O-6-13-iii
3.774.988
3.888.237
3.963.737
4.039.237
48.481.088
49.935.521
50.905.143
51.874.764
59.987.763
61.787.396
62.987.151
64.186.906
70.408.818
72.521.082
73.929.258
75.337.435
58.738.622
60.500.781
61.675.553
62.850.326
67.379.246
69.400.623
70.748.208
72.095.793
76.985.606
79.295.174
80.834.886
82.374.598
3.249.059
3.346.530
3.411.511
3.476.493
4.548.682
4.685.142
4.776.116
4.867.090
7.165.206
7.380.162
7.523.466
7.666.770
29.016.375
29.886.866
30.467.193
31.047.521
37.656.998
38.786.708
39.539.848
40.292.988
53.990.657
55.610.377
56.690.190
57.770.003
586
P-8-01-i
587
P-8-01-ii
588
P-8-01-iii
589
P-8-02-i
590
P-8-02-ii
591
P-8-02-iii
592
P-8-03-i
593
P-8-03-ii
594
P-8-03-iii
595
P-8-04-i
596
P-8-04-ii
597
P-8-04-iii

SALURAN URIN SEDANG
SALURAN URIN BERAT
RINGAN
SEDANG
BERAT
&KURET RINGAN
KURET SEDANG
KURET BERAT

Regional 4
- 298 No
Kode
INA-CBG
598
P-8-05-i
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii
603
P-8-06-iii
604
P-8-07-i
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
614
P-8-11-ii
615
P-8-11-iii
616
P-8-12-i
617
P-8-12-ii
618
P-8-12-iii
619
P-8-13-i
620
P-8-13-ii
621
P-8-13-iii
622
P-8-14-i
623
P-8-14-ii
624
P-8-14-iii
625
P-8-15-i
Deskripsi (INA-CBG)
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
RINGAN
SEDANG
BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
ASPIRASI RINGAN
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
15.778.164
16.251.509
16.567.072
16.882.635
22.363.420
23.034.323
23.481.591
23.928.859
32.949.497
33.937.982
34.596.972
35.255.962
2.599.247
2.677.224
2.729.209
2.781.194
6.540.386
6.736.598
6.867.405
6.998.213
12.165.864
12.530.840
12.774.157
13.017.475
4.548.682
4.685.142
4.776.116
4.867.090
12.753.409
13.136.012
13.391.080
13.646.148
16.895.104
17.401.957
17.739.860
18.077.762
3.296.347
3.395.237
3.461.164
3.527.091
4.679.628
4.820.017
4.913.610
5.007.202
6.606.198
6.804.384
6.936.508
7.068.632
2.045.050
2.106.401
2.147.302
2.188.203
2.962.552
3.051.429
3.110.680
3.169.931
5.816.363
5.990.854
6.107.181
6.223.509
5.759.730
5.932.521
6.047.716
6.162.911
12.262.306
12.630.176
12.875.422
13.120.668
12.519.204
12.894.780
13.145.164
13.395.548
2.717.289
2.798.808
2.853.154
2.907.500
4.224.913
4.351.660
4.436.159
4.520.657
4.984.504
5.134.039
5.233.729
5.333.419
1.404.442
1.446.575
1.474.664
1.502.752
2.598.908
2.676.875
2.728.854
2.780.832
3.886.945
4.003.553
4.081.292
4.159.031
2.566.061
2.643.043
2.694.364
2.745.685
5.239.170
5.396.345
5.501.128
5.605.912
5.747.350
5.919.770
6.034.717
6.149.664
1.929.758
1.987.650
2.026.246
2.064.841
- 299 No
Kode
INA-CBG
626
P-8-15-ii
627
P-8-15-iii
628
P-8-16-i
629
P-8-16-ii
630
P-8-16-iii
631
P-8-17-i
632
P-8-17-ii
633
P-8-17-iii
634
S-4-10-i
635
S-4-10-ii
636
S-4-10-iii
637
S-4-11-i
638
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
3.857.078
3.972.791
4.049.932
4.127.074
4.530.736
4.666.658
4.757.272
4.847.887
1.746.887
1.799.293
1.834.231
1.869.169
2.478.034
2.552.375
2.601.935
2.651.496
3.216.609
3.313.108
3.377.440
3.441.772
1.152.941
1.187.530
1.210.589
1.233.647
3.829.682
3.944.572
4.021.166
4.097.759
7.729.968
7.961.867
8.116.467
8.271.066
1.929.531
1.987.417
2.026.008
2.064.598
2.411.914
2.484.271
2.532.510
2.580.748
3.135.074
3.229.126
3.291.828
3.354.529
1.205.957
1.242.136
1.266.255
1.290.374
S-4-11-ii
1.835.489
1.890.554
1.927.264
1.963.974
639
S-4-11-iii
2.969.501
3.058.586
3.117.976
3.177.366
640
S-4-12-i
1.447.148
1.490.563
1.519.506
1.548.449
641
S-4-12-ii
1.929.531
1.987.417
2.026.008
2.064.598
642
S-4-12-iii
3.768.527
3.881.583
3.956.953
4.032.324
1.929.531
1.987.417
2.026.008
2.064.598
3.410.978
3.513.308
3.581.527
3.649.747
6.945.186
7.153.541
7.292.445
7.431.349
1.175.628
1.210.897
1.234.409
1.257.922
2.497.428
2.572.351
2.622.299
2.672.248
4.736.013
4.878.093
4.972.814
5.067.534
889.138
915.812
933.595
951.378
1.678.107
1.728.450
1.762.012
1.795.574
2.173.538
2.238.744
2.282.215
2.325.686

ASPIRASI SEDANG
ASPIRASI BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT

PASIEN RINGAN
PASIEN SEDANG
PASIEN BERAT
Regional 4
643
S-4-13-i
644
S-4-13-ii
645
S-4-13-iii
646
S-4-14-i
647
S-4-14-ii
648
S-4-14-iii
649
S-4-15-i
650
S-4-15-ii
651
S-4-15-iii
652
S-4-16-i
LUKA BAKAR RINGAN
3.376.680
3.477.980
3.545.513
3.613.047
653
S-4-16-ii
LUKA BAKAR SEDANG
4.768.971
4.912.041
5.007.420
5.102.799
654
S-4-16-iii
LUKA BAKAR BERAT
8.515.739
8.771.211
8.941.526
9.111.841
1.800.512
1.854.527
1.890.537
1.926.548
2.411.914
2.484.271
2.532.510
2.580.748
3.933.102
4.051.095
4.129.757
4.208.419
655
S-4-17-i
656
S-4-17-ii
657
S-4-17-iii

- 300 No
Kode
INA-CBG
658
T-1-10-i
659
T-1-10-ii
660
T-1-10-iii
661
T-4-10-i
662
T-4-10-ii
663
T-4-10-iii
664
T-4-11-i
665
T-4-11-ii
666
T-4-11-iii
667
T-4-12-i
668
T-4-12-ii
669
T-4-12-iii
670
U-1-10-i
671
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
1.858.625
1.914.384
1.951.556
1.988.729
2.496.007
2.570.888
2.620.808
2.670.728
4.541.051
4.677.282
4.768.103
4.858.924
813.016
837.406
853.666
869.927
1.549.427
1.595.910
1.626.899
1.657.887
2.252.447
2.320.020
2.365.069
2.410.118
804.026
828.147
844.227
860.308
1.265.308
1.303.267
1.328.573
1.353.879
2.038.038
2.099.179
2.139.940
2.180.701
1.688.340
1.738.990
1.772.757
1.806.524
2.551.833
2.628.388
2.679.424
2.730.461
3.969.735
4.088.827
4.168.221
4.247.616
1.797.083
1.850.996
1.886.937
1.922.879
U-1-10-ii
3.667.058
3.777.070
3.850.411
3.923.752
672
U-1-10-iii
15.835.098
16.310.151
16.626.853
16.943.555
673
U-1-11-i
674
U-1-11-ii
675
U-1-11-iii
676

DOKTER RINGAN
DOKTER SEDANG
DOKTER BERAT
Regional 4

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
7.797.740
8.031.673
8.187.627
8.343.582
10.396.987
10.708.897
10.916.837
11.124.776
17.467.864
17.991.900
18.341.257
18.690.615
U-1-12-i
4.765.283
4.908.242
5.003.548
5.098.853
677
U-1-12-ii
11.696.611
12.047.509
12.281.441
12.515.373
678
U-1-12-iii
15.188.270
15.643.919
15.947.684
16.251.449
679
U-1-13-i
5.198.494
5.354.448
5.458.418
5.562.388
680
U-1-13-ii
5.865.311
6.041.271
6.158.577
6.275.883
681
U-1-13-iii
11.309.974
11.649.274
11.875.473
12.101.673
2.868.365
2.954.416
3.011.784
3.069.151
3.520.061
3.625.663
3.696.064
3.766.465
4.171.371
4.296.513
4.379.940
4.463.367

682
U-1-14-i
683
U-1-14-ii
684
U-1-14-iii
685
U-1-15-i
1.684.700
1.735.241
1.768.935
1.802.629
686
U-1-15-ii
2.393.842
2.465.657
2.513.534
2.561.410
687
U-1-15-iii
4.717.161
4.858.676
4.953.019
5.047.362
U-1-20-i

4.357.586
4.488.314
4.575.465
4.662.617
688
- 301 No
Kode
INA-CBG
689
U-1-20-ii
690
U-1-20-iii
691
U-1-30-i
692
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
7.756.503
7.989.198
8.144.328
8.299.458
19.135.576
19.709.643
20.092.355
20.475.066
3.738.049
3.850.190
3.924.951
3.999.712
U-1-30-ii
5.046.366
5.197.757
5.298.684
5.399.612
693
U-1-30-iii
9.892.328
10.189.098
10.386.945
10.584.791
694
U-4-10-i
3.479.499
3.583.884
3.653.474
3.723.064
695
U-4-10-ii
8.722.374
8.984.045
9.158.492
9.332.940
696
U-4-10-iii
12.724.044
13.105.765
13.360.246
13.614.727
697
U-4-11-i
1.929.531
1.987.417
2.026.008
2.064.598
698
U-4-11-ii
2.894.297
2.981.126
3.039.012
3.096.897
699
U-4-11-iii
4.002.801
4.122.885
4.202.941
4.282.997
700
U-4-12-i
1.929.531
1.987.417
2.026.008
2.064.598
701
U-4-12-ii
2.249.389
2.316.871
2.361.858
2.406.846
702
U-4-12-iii
3.576.426
3.683.719
3.755.247
3.826.776
703
U-4-13-i
1.895.622
1.952.491
1.990.403
2.028.316
704
U-4-13-ii
2.203.772
2.269.885
2.313.960
2.358.036
705
U-4-13-iii
2.502.221
2.577.288
2.627.332
2.677.377
706
U-4-14-i
2.411.914
2.484.271
2.532.510
2.580.748
707
U-4-14-ii
2.894.297
2.981.126
3.039.012
3.096.897
708
U-4-14-iii
4.848.449
4.993.903
5.090.872
5.187.841
709
U-4-15-i
1.929.531
1.987.417
2.026.008
2.064.598
710
U-4-15-ii
2.411.914
2.484.271
2.532.510
2.580.748
711
U-4-15-iii
3.377.334
3.478.654
3.546.201
3.613.747
712
V-1-10-i
5.640.659
5.809.879
5.922.692
6.035.505
713
V-1-10-ii
6.498.117
6.693.061
6.823.023
6.952.985
714
V-1-10-iii
12.346.422
12.716.815
12.963.744
13.210.672
715
V-1-11-i
6.498.117
6.693.061
6.823.023
6.952.985
716
V-1-11-ii
7.252.008
7.469.568
7.614.608
7.759.648
717
V-1-11-iii
10.739.113
11.061.286
11.276.069
11.490.851
3.509.506
3.614.791
3.684.981
3.755.171
13.412.165
13.814.530
14.082.773
14.351.016
15.659.924
16.129.722
16.442.921
16.756.119
5.319.273
5.478.851
5.585.237
5.691.622
718
V-1-12-i
719
V-1-12-ii
720
V-1-12-iii
721
V-1-13-i


DAN TELINGA RINGAN
DAN TELINGA SEDANG
DAN TELINGA BERAT


KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

Regional 4
- 302 No
Kode
INA-CBG
722
V-1-13-ii
723
V-1-13-iii
724
V-1-14-i
725
V-1-14-ii
726
V-1-14-iii
727
V-1-15-i
728
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
10.108.145
10.411.390
10.613.553
10.815.716
15.595.481
16.063.345
16.375.255
16.687.165
6.412.446
6.604.819
6.733.068
6.861.317
9.326.353
9.606.143
9.792.670
9.979.197
12.677.820
13.058.154
13.311.711
13.565.267
3.023.111
3.113.804
3.174.267
3.234.729
V-1-15-ii
5.758.438
5.931.191
6.046.360
6.161.529
729
V-1-15-iii
10.123.224
10.426.921
10.629.385
10.831.850
730
V-4-10-i
4.867.972
5.014.011
5.111.371
5.208.730
731
V-4-10-ii
6.287.567
6.476.194
6.601.946
6.727.697
732
V-4-10-iii
12.016.645
12.377.144
12.617.477
12.857.810
733
V-4-11-i
2.475.546
2.549.812
2.599.323
2.648.834
734
V-4-11-ii
3.617.168
3.725.683
3.798.027
3.870.370
735
V-4-11-iii
5.968.088
6.147.131
6.266.493
6.385.854
736
W-1-01-i
7.279.318
7.497.697
7.643.284
7.788.870
737
W-1-01-ii
8.767.593
9.030.621
9.205.973
9.381.324
738
W-1-01-iii
19.365.871
19.946.847
20.334.165
20.721.482
739
W-1-10-i
2.027.281
2.088.100
2.128.645
2.169.191
740
W-1-10-ii
3.783.239
3.896.737
3.972.401
4.048.066
741
W-1-10-iii
6.188.179
6.373.825
6.497.588
6.621.352
742
W-1-11-i
2.105.671
2.168.841
2.210.955
2.253.068
743
W-1-11-ii
4.061.053
4.182.885
4.264.106
4.345.327
744
W-1-11-iii
7.797.740
8.031.673
8.187.627
8.343.582
745
W-1-12-i
1.913.319
1.970.718
2.008.985
2.047.251
746
W-1-12-ii
2.175.407
2.240.669
2.284.177
2.327.685
747
W-1-12-iii
3.341.699
3.441.950
3.508.784
3.575.618
748
W-1-13-i
2.277.301
2.345.620
2.391.166
2.436.712
749
W-1-13-ii
2.472.493
2.546.668
2.596.118
2.645.567
750
W-1-13-iii
3.321.014
3.420.645
3.487.065
3.553.485
751
W-1-20-i
6.204.997
6.391.147
6.515.247
6.639.347
752
W-1-20-ii
8.728.260
8.990.108
9.164.673
9.339.238
753
W-1-20-iii
11.026.252
11.357.040
11.577.565
11.798.090

NON KOMPLEK (BERAT)

RINGAN
SEDANG
BERAT

SERVIK RINGAN
SERVIK SEDANG
SERVIK BERAT
ENDOSKOP RINGAN
ENDOSKOP SEDANG
ENDOSKOP BERAT
Regional 4
- 303 No
Kode
INA-CBG
754
W-1-30-i
755
W-1-30-ii
756
W-1-30-iii
757
W-4-10-i
758
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
3.387.306
3.488.926
3.556.672
3.624.418
5.402.929
5.565.017
5.673.075
5.781.134
14.367.717
14.798.749
15.086.103
15.373.457
2.526.082
2.601.864
2.652.386
2.702.908
W-4-10-ii
3.414.283
3.516.711
3.584.997
3.653.282
759
W-4-10-iii
7.718.125
7.949.668
8.104.031
8.258.393
760
W-4-11-i
2.411.914
2.484.271
2.532.510
2.580.748
761
W-4-11-ii
3.859.062
3.974.834
4.052.015
4.129.197
762
W-4-11-iii
4.689.904
4.830.602
4.924.400
5.018.198
1.929.531
1.987.417
2.026.008
2.064.598
2.653.105
2.732.698
2.785.761
2.838.823
2.957.918
3.046.655
3.105.814
3.164.972

RINGAN
SEDANG
BERAT

Regional 4
763
W-4-12-i
764
W-4-12-ii
765
W-4-12-iii
766
W-4-13-i
ABORTUS RINGAN
1.058.178
1.089.923
1.111.087
1.132.250
767
W-4-13-ii
ABORTUS SEDANG
1.447.148
1.490.563
1.519.506
1.548.449
768
W-4-13-iii
ABORTUS BERAT
1.929.531
1.987.417
2.026.008
2.064.598
769
W-4-14-i
1.447.148
1.490.563
1.519.506
1.548.449
770
W-4-14-ii
1.861.266
1.917.104
1.954.330
1.991.555
771
W-4-14-iii
2.342.043
2.412.304
2.459.145
2.505.986
772
W-4-15-i
1.206.753
1.242.956
1.267.091
1.291.226
773
W-4-15-ii
1.342.140
1.382.404
1.409.247
1.436.089
774
W-4-15-iii
1.858.320
1.914.069
1.951.236
1.988.402
775
W-4-16-i
1.447.148
1.490.563
1.519.506
1.548.449
776
W-4-16-ii
1.929.531
1.987.417
2.026.008
2.064.598
777
W-4-16-iii
2.630.653
2.709.573
2.762.186
2.814.799
778
W-4-17-i
1.181.967
1.217.426
1.241.065
1.264.704
779
W-4-17-ii
1.929.531
1.987.417
2.026.008
2.064.598
780
W-4-17-iii
3.650.289
3.759.798
3.832.804
3.905.809
781
Z-4-10-i
REHABILITASI RINGAN
3.310.847
3.410.172
3.476.389
3.542.606
782
Z-4-10-ii
REHABILITASI SEDANG
4.394.671
4.526.512
4.614.405
4.702.298
783
Z-4-10-iii
REHABILITASI BERAT
6.243.050
6.430.341
6.555.202
6.680.063
784
Z-4-11-i
2.890.005
2.976.705
3.034.505
3.092.305
785
Z-4-11-ii
3.478.927
3.583.295
3.652.874
3.722.452
786
Z-4-11-iii
5.504.281
5.669.410
5.779.496
5.889.581
1.447.148
1.490.563
1.519.506
1.548.449
2.948.517
3.036.973
3.095.943
3.154.913
3.747.098
3.859.511
3.934.453
4.009.395
787
Z-4-12-i
788
Z-4-12-ii
789
Z-4-12-iii

b. RawatJalan
No
Kode
INA-CBG
B-2-10-0
B-2-11-0
- 304 -
Deskripsi (INA-CBG)
LAPAROSKOPI
PANKREAS
LAPAROSKOPI
EMPEDU
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
800.166
824.171
840.174
856.178
1.037.940
1.069.079
1.089.837
1.110.596
1.930.187
1.988.093
2.026.696
2.065.300
1.595.112
1.642.966
1.674.868
1.706.770
1.332.579
1.372.556
1.399.208
1.425.859
467.208
481.224
490.568
499.913
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
1.041.813
1.073.067
1.093.903
1.114.739
B-3-12-0

214.058
220.480
224.761
229.042
C-3-10-0
583.921
601.438
613.117
624.795
10
C-3-11-0

KANDUNG KEMIH
923.492
951.197
969.667
988.137
11
C-3-12-0
209.354
215.634
219.822
224.009
12
C-3-13-0
203.297
209.396
213.462
217.528
13
C-3-14-0
1.730.670
1.782.590
1.817.203
1.851.817
14
C-3-15-0
1.586.228
1.633.815
1.665.539
1.697.264
15
C-3-16-0
359.718
370.510
377.704
384.899
16
C-3-17-0

LEHER
238.627
245.785
250.558
255.330
17
C-3-18-0
105.797
108.971
111.087
113.202
18
C-3-19-0

MYELOMA ATAU TESTIS
149.618
154.107
157.099
160.091
19
C-3-20-0
2.979.648
3.069.038
3.128.631
3.188.224
20
C-3-21-0
170.741
175.863
179.278
182.693
21
C-3-22-0
749.644
772.133
787.126
802.119
22
C-3-23-0
121.426
125.069
127.497
129.926
23
D-2-10-0

TULANG
1.028.737
1.059.599
1.080.174
1.100.749
24
D-2-11-0
PROSEDUR LIMPA
1.288.155
1.326.799
1.352.563
1.378.326
25
D-2-21-0
1.080.397
1.112.809
1.134.417
1.156.025
26
D-2-22-0
237.115
244.228
248.970
253.713
27
D-3-10-0
171.748
176.900
180.335
183.770
28
D-3-11-0
445.907
459.284
468.203
477.121
29
E-2-10-0
264.509
272.444
277.734
283.024
30
E-2-21-0
191.760
197.513
201.348
205.183
31
E-2-22-0
191.760
197.513
201.348
205.183

OVARIUM
GASTROINTESTINAL
GINJAL ATAU PROSTAT

TYMUS
TYMUS
TULANG
PEMBENTUK DARAH
PARATIROID
THYROGLOSSAL
- 305 No
Kode
INA-CBG
32
E-3-10-0
33
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

ENDOKRIN
223.004
229.694
234.155
238.615
F-3-10-0
TERAPI SHOCK
311.084
320.416
326.638
332.860
34
F-5-10-0
381.178
392.614
400.237
407.861
35
F-5-11-0
TERAPI KELOMPOK
251.352
258.893
263.920
268.947
36
F-5-12-0
321.648
331.297
337.730
344.163
37
F-5-13-0
272.414
280.587
286.035
291.483
38
F-5-14-0
182.753
188.236
191.891
195.546
39
F-5-15-0
171.446
176.590
180.019
183.447
40
F-5-16-0
178.578
183.935
187.507
191.078
41
G-2-10-0
150.376
154.887
157.895
160.903
42
G-2-11-0
1.303.524
1.342.630
1.368.700
1.394.771
43
G-2-12-0

EKSTRAKRANIAL
1.889.128
1.945.801
1.983.584
2.021.366
44
G-2-13-0
463.445
477.348
486.617
495.886
45
G-2-21-0
845.246
870.603
887.508
904.413
46
G-2-22-0
767.132
790.146
805.489
820.832
47
G-2-31-0
1.265.835
1.303.810
1.329.127
1.354.444
48
G-2-32-0
648.866
668.332
681.309
694.287
49
G-3-10-0
257.539
265.265
270.416
275.567
50
G-3-11-0
342.993
353.282
360.142
367.002
51
G-3-12-0
561.999
578.859
590.099
601.339
52
G-3-13-0
562.063
578.925
590.167
601.408
53
H-2-21-0
737.625
759.754
774.506
789.259
54
H-2-22-0
191.760
197.513
201.348
205.183
55
H-2-23-0
191.760
197.513
201.348
205.183
56
H-2-31-0
1.221.814
1.258.469
1.282.905
1.307.341
57
H-2-32-0
127.162
130.977
133.520
136.064
58
H-2-33-0
191.760
197.513
201.348
205.183
59
H-2-34-0
548.136
564.580
575.542
586.505
60
H-2-35-0
180.623
186.042
189.654
193.267
61
H-2-36-0
974.961
1.004.210
1.023.710
1.043.209
62
H-2-37-0

1.037.889
1.069.026
1.089.784
1.110.542
63
H-3-10-0
361.110
371.943
379.165
386.387
64
H-3-11-0
189.904
195.601
199.399
203.197

AKUT
MENTAL
PROSEDUR KRANIOTOMI

MATA
MATA
MATA
MATA
MATA
- 306 No
Kode
INA-CBG
65
H-3-12-0
66
H-3-13-0
67
I-2-11-0
68
I-2-12-0
69
I-2-13-0
70
I-2-14-0
71
I-2-15-0
Deskripsi (INA-CBG)
MATA
TORASIK
ABDOMEN
PENGGANTIAN ALAT
DARAH VENA
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
198.269
204.217
208.183
212.148
192.507
198.283
202.133
205.983
2.220.020
2.286.620
2.331.021
2.375.421
1.560.916
1.607.744
1.638.962
1.670.180
1.983.831
2.043.345
2.083.022
2.122.699
3.510.958
3.616.286
3.686.505
3.756.725
211.142
217.476
221.699
225.922
2.217.614
2.284.142
2.328.495
2.372.847
731.084
753.016
767.638
782.259
72
I-2-16-0
73
I-2-17-0
74
I-2-21-0
1.711.683
1.763.033
1.797.267
1.831.500
75
I-2-22-0
1.611.849
1.660.204
1.692.441
1.724.678
76
I-2-23-0
329.860
339.756
346.353
352.950
77
I-2-31-0
2.565.433
2.642.396
2.693.705
2.745.014
78
I-2-32-0
3.354.681
3.455.321
3.522.415
3.589.508
79
I-2-41-0
2.249.355
2.316.835
2.361.822
2.406.809
80
I-2-42-0

LAIN
2.615.247
2.693.704
2.746.009
2.798.314
81
I-3-10-0
PROSEDUR RESUSITASI
331.982
341.942
348.581
355.221
82
I-3-11-0
175.220
180.476
183.981
187.485
83
I-3-12-0
1.018.310
1.048.859
1.069.225
1.089.591
84
I-3-13-0
334.452
344.486
351.175
357.864
85
I-3-14-0
214.373
220.804
225.091
229.379
189.904
195.601
199.399
203.197
1.175.761
1.211.034
1.234.549
1.258.065
189.532
195.218
199.009
202.800
955.125
983.779
1.002.882
1.021.984
1.238.883
1.276.050
1.300.827
1.325.605

PACU JANTUNG

KARDIOVASKULAR
PERNAFASAN
PENDEK
86
I-3-15-0
87
J-2-10-0
88
J-2-21-0
89
J-2-22-0
90
J-2-31-0
91
J-2-32-0
921.935
949.593
968.031
986.470
92
J-3-10-0
191.760
197.513
201.348
205.183
93
J-3-11-0

PADA DADA
541.879
558.136
568.973
579.811
94
J-3-12-0
209.354
215.634
219.822
224.009
95
J-3-13-0
308.117
317.360
323.522
329.685
96
J-3-14-0
327.099
336.912
343.454
349.996
- 307 No
Kode
INA-CBG
97
J-3-15-0
98
J-3-16-0
99
J-3-17-0
100
K-2-10-0
101
K-2-11-0
102
K-2-12-0

103
K-2-13-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
286.840
295.445
301.182
306.919
327.099
336.912
343.454
349.996
191.760
197.513
201.348
205.183
551.950
568.509
579.548
590.587
1.178.639
1.213.999
1.237.571
1.261.144
904.758
931.900
949.996
968.091
1.472.542
1.516.718
1.546.169
1.575.620
191.760
197.513
201.348
205.183
191.760
197.513
201.348
205.183
2.464.571
2.538.508
2.587.799
2.637.091
828.710
853.571
870.145
886.719
191.760
197.513
201.348
205.183

PERNAFASAN
KECIL

FEMORALIS
USUS BESAR
ATAS
ATAS
104
K-2-14-0
105
K-2-21-0
106
K-2-22-0
107
K-2-31-0
108
K-2-32-0
109
K-2-41-0
912.841
940.226
958.483
976.740
110
K-2-42-0

260.810
268.634
273.850
279.067
111
K-2-51-0
604.904
623.051
635.149
647.247
112
K-2-52-0
329.860
339.756
346.353
352.950
113
K-2-53-0
191.760
197.513
201.348
205.183
114
K-3-10-0

GASTROINTESTINAL
364.906
375.853
383.151
390.450
115
K-3-11-0
219.380
225.961
230.349
234.736
116
K-3-12-0
222.479
229.153
233.603
238.052
117
K-3-13-0
191.760
197.513
201.348
205.183
513.921
529.338
539.617
549.895
248.179
255.625
260.588
265.552
328.854
338.719
345.296
351.873
1.130.610
1.164.529
1.187.141
1.209.753
724.713
746.455
760.949
775.443
327.099
336.912
343.454
349.996
329.860
339.756
346.353
352.950

GASTROINTESTINAL
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
118
K-3-14-0
119
K-3-15-0
120
K-3-16-0
121
L-2-21-0
122
L-2-22-0
123
L-2-31-0
124
L-2-32-0
125
L-2-41-0
987.727
1.017.359
1.037.113
1.056.868
126
L-2-42-0

221.531
228.177
232.608
237.038
127
L-2-51-0
1.478.782
1.523.145
1.552.721
1.582.297
L-2-52-0

1.131.317
1.165.256
1.187.883
1.210.509
128
- 308 No
Kode
INA-CBG
129
L-2-53-0
130
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

191.760
197.513
201.348
205.183
L-3-10-0
260.810
268.634
273.850
279.067
131
L-3-11-0
253.264
260.862
265.928
270.993
132
L-3-12-0
192.885
198.672
202.529
206.387
133
M-2-10-0
2.787.733
2.871.365
2.927.120
2.982.874
134
M-2-21-0
2.496.608
2.571.506
2.621.438
2.671.370
135
M-2-22-0
607.813
626.048
638.204
650.360
136
M-2-31-0
1.516.438
1.561.932
1.592.260
1.622.589
137
M-2-32-0
480.579
494.996
504.608
514.219
138
M-2-41-0

TULANG
480.579
494.996
504.608
514.219
139
M-2-42-0
165.621
170.589
173.902
177.214
140
M-2-51-0
353.344
363.945
371.012
378.078
141
M-2-52-0
353.344
363.945
371.012
378.078
142
M-2-61-0
PROSEDUR ARTROSKOPI
1.731.926
1.783.883
1.818.522
1.853.160
143
M-2-62-0
353.344
363.945
371.012
378.078
1.741.295
1.793.533
1.828.359
1.863.185
2.374.766
2.446.009
2.493.504
2.541.000
353.344
363.945
371.012
378.078
1.753.202
1.805.798
1.840.862
1.875.926
1.691.914
1.742.672
1.776.510
1.810.348

DAN WAJAH
PAHA
PAHA
PROSEDUR BUNION

TULANG
WAJAH
WAJAH
BAWAH
BAWAH
144
M-2-63-0
145
M-2-64-0
146
M-2-65-0
147
M-2-71-0
148
M-2-72-0
149
M-2-81-0
2.523.004
2.598.694
2.649.155
2.699.615
150
M-2-82-0
1.832.801
1.887.785
1.924.441
1.961.097
151
M-2-83-0
353.344
363.945
371.012
378.078
152
M-2-84-0
353.344
363.945
371.012
378.078
153
M-3-10-0
1.008.513
1.038.768
1.058.939
1.079.109
154
M-3-11-0
559.159
575.934
587.117
598.300
155
M-3-12-0
1.264.495
1.302.430
1.327.720
1.353.010
156
M-3-13-0
412.260
424.627
432.873
441.118
157
M-3-14-0

TERTUTUP
704.621
725.760
739.852
753.945
158
M-3-15-0
310.429
319.742
325.950
332.159
159
M-3-16-0

353.344
363.945
371.012
378.078
160
M-3-17-0
385.764
397.337
405.052
412.767
161
N-2-11-0
2.533.336
2.609.336
2.660.002
2.710.669

PERGELANGAN TANGAN
PERGELANGAN TANGAN
MUSKULOSKELETAL
SKELETAL
- 309 No
Kode
INA-CBG
162
N-2-12-0
163
N-2-21-0
164
N-2-22-0
165
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.465.510
1.509.475
1.538.785
1.568.095
1.457.785
1.501.518
1.530.674
1.559.830
329.860
339.756
346.353
352.950
N-2-23-0
329.860
339.756
346.353
352.950
166
N-2-24-0
1.065.997
1.097.977
1.119.297
1.140.617
167
N-2-31-0
897.397
924.319
942.267
960.214
168
N-2-32-0
329.860
339.756
346.353
352.950
169
N-2-41-0
329.860
339.756
346.353
352.950
170
N-2-42-0
557.857
574.592
585.749
596.907
171
N-3-10-0
329.860
339.756
346.353
352.950
172
N-3-11-0
382.190
393.656
401.300
408.943
173
N-3-12-0
295.335
304.195
310.102
316.008
174
N-3-13-0
329.860
339.756
346.353
352.950
175
N-3-14-0
283.827
292.341
298.018
303.695
176
N-3-15-0
727.803
749.637
764.193
778.749
177
O-7-10-0
121.512
125.157
127.587
130.018
178
O-7-11-0
669.197
689.273
702.657
716.041
179
O-7-12-0
243.677
250.988
255.861
260.735
180
O-7-13-0
135.425
139.488
142.196
144.905
181
P-9-10-0
180.623
186.042
189.654
193.267
182
P-9-11-0
180.623
186.042
189.654
193.267
183
P-9-12-0
180.623
186.042
189.654
193.267
184
P-9-13-0
180.623
186.042
189.654
193.267
185
P-9-14-0
180.623
186.042
189.654
193.267
186
P-9-15-0
115.133
118.587
120.890
123.192
187
P-9-16-0
180.623
186.042
189.654
193.267
188
P-9-17-0
179.846
185.242
188.839
192.436
189
Q-5-10-0
235.410
242.472
247.180
251.888
190
Q-5-11-0
176.433
181.726
185.255
188.783
191
Q-5-12-0
GIGI
155.503
160.169
163.279
166.389
192
Q-5-13-0
MEDICAL CHECK-UP
118.176
121.721
124.085
126.448
193
Q-5-14-0
130.032
133.933
136.534
139.134


DAN URETHRA
URETHRA
TRANSURETHRA
TRANSURETHRA
SALURAN KEMIH
KEMIH
KEMIH
PROSEDUR DIALISIS
CAESAR
VAGINAL/JALAN LAHIR

ASPIRASI
- 310 No
Kode
INA-CBG
194
Q-5-15-0
195
Q-5-16-0
VAKSINASI
196
Q-5-17-0
PASANG INFUS
197
Q-5-18-0
198
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
89.423
92.106
93.894
95.683
101.069
104.101
106.122
108.143
87.422
90.044
91.793
93.541
164.555
169.492
172.783
176.074
Q-5-19-0
183.963
189.481
193.161
196.840
199
Q-5-20-0
ABORSI MENGANCAM
123.304
127.003
129.469
131.935
200
Q-5-21-0
ABORSI
121.625
125.273
127.706
130.138
201
Q-5-22-0
130.032
133.933
136.534
139.134
202
Q-5-23-0
159.194
163.969
167.153
170.337
203
Q-5-24-0
108.727
111.989
114.163
116.338
204
Q-5-25-0
169.557
174.644
178.035
181.426
205
Q-5-26-0
BRONKIAL AKUT
239.997
247.197
251.997
256.797
206
Q-5-27-0
170.793
175.917
179.333
182.749
207
Q-5-28-0
138.594
142.752
145.524
148.296
208
Q-5-29-0

JANTUNG LAIN-LAIN
392.384
404.155
412.003
419.850
209
Q-5-30-0
454.730
468.372
477.467
486.561
210
Q-5-31-0
FRAKTUR
162.230
167.096
170.341
173.586
211
Q-5-32-0
SALURAN KEMIH AKUT
187.898
193.535
197.293
201.051
212
Q-5-33-0
HEMATOLOGI AKUT
196.729
202.631
206.565
210.500
213
Q-5-34-0
INFEKSI VIRUS HIV
279.467
287.851
293.441
299.030
214
Q-5-35-0
INFEKSI AKUT
316.908
326.416
332.754
339.092
215
Q-5-36-0
369.060
380.132
387.513
394.894
216
Q-5-37-0

SHOCK
188.240
193.887
197.652
201.416
217
Q-5-38-0
PARU AKUT
251.024
258.554
263.575
268.595
218
Q-5-39-0
160.637
165.456
168.668
171.881
219
Q-5-40-0
157.610
162.339
165.491
168.643
220
Q-5-41-0
218.189
224.735
229.098
233.462
221
Q-5-42-0
171.069
176.201
179.622
183.044
222
Q-5-43-0
246.349
253.739
258.666
263.593
223
Q-5-44-0
201.055
207.087
211.108
215.129
224
T-2-10-0

TERAPI DETOKSIKASI
104.284
107.412
109.498
111.584
225
U-2-10-0
1.391.785
1.433.539
1.461.375
1.489.210
226
U-2-11-0

LEHER
1.654.292
1.703.920
1.737.006
1.770.092
227
U-2-12-0
182.015
187.476
191.116
194.756
- 311 No
Kode
INA-CBG
228
U-2-13-0
229
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
238.627
245.785
250.558
255.330
U-2-14-0
443.260
456.558
465.423
474.288
230
U-2-15-0
251.851
259.406
264.443
269.480
231
U-2-21-0
293.367
302.168
308.035
313.902
232
U-2-22-0
566.808
583.812
595.148
606.484
233
U-2-23-0
742.701
764.982
779.836
794.690
234
U-2-24-0
625.936
644.714
657.233
669.751
235
U-2-25-0
238.627
245.785
250.558
255.330
236
U-2-31-0
191.760
197.513
201.348
205.183
237
U-2-32-0
238.627
245.785
250.558
255.330
238
U-3-10-0
228.140
234.984
239.546
244.109
239
U-3-11-0
242.213
249.479
254.324
259.168
240
U-3-12-0
107.106
110.319
112.462
114.604
241
U-3-13-0
235.428
242.491
247.199
251.908
242
U-3-14-0
216.310
222.799
227.125
231.451
243
U-3-15-0
188.641
194.301
198.073
201.846
244
U-3-16-0
PROSEDUR PADA GIGI
212.753
219.136
223.391
227.646
245
V-2-10-0

PROSTAT
2.075.654
2.137.923
2.179.436
2.220.949
246
V-2-11-0
234.081
241.103
245.785
250.467
746.986
769.395
784.335
799.275
329.860
339.756
346.353
352.950
329.860
339.756
346.353
352.950

(RHINOPLASTY)

RONGGA HIDUNG
TENGGOROKAN
PROSEDUR PADA PENIS

SKROTUM
SKROTUM
TRANSURETHRAL
247
V-2-12-0
248
V-2-13-0
249
V-2-14-0
250
V-2-15-0
SIRKUMSISI/SUNAT
180.623
186.042
189.654
193.267
251
V-3-10-0
376.702
388.003
395.537
403.071
252
V-3-11-0
796.919
820.827
836.765
852.704
253
V-3-12-0
460.083
473.885
483.087
492.288
254
W-2-10-0
168.470
173.524
176.893
180.262
255
W-2-11-0
430.545
443.462
452.073
460.684
256
W-2-12-0
796.919
820.827
836.765
852.704
257
W-2-13-0
127.812
131.646
134.202
136.758
258
W-2-21-0
1.602.020
1.650.081
1.682.121
1.714.162
259
W-2-22-0
168.470
173.524
176.893
180.262

PROSEDUR ABORSI
RAHIM & LEHER RAHIM
TERHALANG/TERGANGGU
TERHALANG/TERGANGGU
PANGGUL TERBUKA
PANGGUL TERBUKA
- 312 No
Kode
INA-CBG
260
W-2-23-0
Deskripsi (INA-CBG)
JALAN LAHIR
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
562.191
579.057
590.301
601.545
1.845.502
1.900.867
1.937.777
1.974.688
1.294.335
1.333.165
1.359.051
1.384.938
261
W-2-31-0
262
W-2-32-0
263
W-2-33-0
550.109
566.613
577.615
588.617
264
W-2-34-0
187.102
192.715
196.457
200.199
265
W-3-10-0
454.730
468.372
477.466
486.561
266
W-3-11-0
363.498
374.403
381.673
388.943
267
W-3-12-0
168.470
173.524
176.893
180.262
268
Z-3-10-0
1.907.300
1.964.519
2.002.665
2.040.811
269
Z-3-11-0

EMPEDU
1.457.785
1.501.518
1.530.674
1.559.830
270
Z-3-12-0
243.415
250.717
255.586
260.454
271
Z-3-13-0

LAIN-LAIN
1.485.384
1.529.945
1.559.653
1.589.361
272
Z-3-14-0
DIAGNOSTIK TIDUR
293.706
302.518
308.392
314.266
273
Z-3-15-0
191.760
197.513
201.348
205.183
274
Z-3-16-0

(MRI)
615.491
633.956
646.265
658.575
275
Z-3-17-0
PENGOBATAN NUKLIR
258.396
266.148
271.316
276.484
276
Z-3-18-0
CT-SCAN KEPALA
248.960
256.429
261.408
266.387
277
Z-3-19-0
CT SCAN LAIN-LAIN
259.119
266.892
272.075
277.257
278
Z-3-20-0
176.233
181.520
185.045
188.569
279
Z-3-21-0
168.470
173.524
176.893
180.262
280
Z-3-22-0
189.934
195.632
199.431
203.230
281
Z-3-23-0
197.833
203.768
207.725
211.681
282
Z-3-24-0
388.703
400.364
408.138
415.912
283
Z-3-25-0
173.128
178.321
181.784
185.247
284
Z-3-26-0
195.668
201.538
205.452
209.365
285
Z-3-27-0
PERAWATAN LUKA
186.810
192.415
196.151
199.887
286
Z-3-28-0
IMAGING PAYUDARA
191.760
197.513
201.348
205.183
287
Z-3-29-0
IMAGING LAIN-LAIN
552.686
569.267
580.321
591.375
288
Z-3-30-0
FOTOTERAPI
93.273
96.071
97.937
99.802
- 313 3. RUMAH SAKIT MATAKELAS B PENDIDIKAN

a. RawatInap
No
Kode
INA-CBG
A-4-10-i
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
SEPTIKEMIA RINGAN
2.736.833
2.818.938
2.873.675
2.928.411
A-4-10-ii
SEPTIKEMIA SEDANG
3.132.938
3.226.926
3.289.585
3.352.244
A-4-10-iii
SEPTIKEMIA BERAT
4.911.856
5.059.212
5.157.449
5.255.686
A-4-11-i
4.918.728
5.066.290
5.164.664
5.263.039
A-4-11-ii
7.598.866
7.826.832
7.978.809
8.130.787
A-4-11-iii
12.430.084
12.802.987
13.051.589
13.300.190
A-4-12-i
DEMAM RINGAN
1.929.531
1.987.417
2.026.008
2.064.598
A-4-12-ii
DEMAM SEDANG
2.767.495
2.850.520
2.905.870
2.961.219
A-4-12-iii
DEMAM BERAT
3.167.195
3.262.211
3.325.555
3.388.898
10
A-4-13-i
2.411.914
2.484.271
2.532.510
2.580.748
11
A-4-13-ii
2.894.297
2.981.126
3.039.012
3.096.897
12
A-4-13-iii
3.517.676
3.623.206
3.693.559
3.763.913
1.929.531
1.987.417
2.026.008
2.064.598
3.064.499
3.156.434
3.217.723
3.279.013
3.489.611
3.594.300
3.664.092
3.733.884
INFEKSI SESUDAH OPERASI & TRAUMA

RINGAN
SEDANG

LAIN-LAIN RINGAN
LAIN-LAIN SEDANG
LAIN-LAIN BERAT
13
A-4-14-i
14
A-4-14-ii
15
A-4-14-iii
16
A-4-15-i
INFEKSI HIV RINGAN
2.894.297
2.981.126
3.039.012
3.096.897
17
A-4-15-ii
INFEKSI HIV SEDANG
4.341.445
4.471.688
4.558.517
4.645.346
18
A-4-15-iii
INFEKSI HIV BERAT
6.037.927
6.219.065
6.339.824
6.460.582
19
B-1-01-i
32.087.791
33.050.425
33.692.181
34.333.937
20
B-1-01-ii
35.401.413
36.463.455
37.171.483
37.879.512
21
B-1-01-iii
62.101.363
63.964.404
65.206.431
66.448.458
22
B-1-10-i
4.160.073
4.284.875
4.368.077
4.451.278
23
B-1-10-ii
10.601.870
10.919.927
11.131.964
11.344.001
24
B-1-10-iii
18.453.662
19.007.272
19.376.345
19.745.418
25
B-1-11-i
2.843.954
2.929.272
2.986.151
3.043.030
26
B-1-11-ii
7.138.592
7.352.750
7.495.521
7.638.293
27
B-1-11-iii
8.950.023
9.218.523
9.397.524
9.576.524
28
B-1-12-i
6.066.256
6.248.243
6.369.568
6.490.893
29
B-1-12-ii
13.001.469
13.391.514
13.651.543
13.911.572
30
B-1-12-iii
15.823.278
16.297.977
16.614.442
16.930.908

(RINGAN)
(SEDANG)
(BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT
- 314 No
Kode
INA-CBG
31
B-1-13-i
32
B-1-13-ii
33
B-1-13-iii
34
B-1-14-i
35
B-1-14-ii
36
B-1-14-iii
37
B-4-10-i
38
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.975.082
4.094.335
4.173.836
4.253.338
6.474.832
6.669.077
6.798.574
6.928.070
9.545.719
9.832.091
10.023.005
10.213.920
5.397.882
5.559.818
5.667.776
5.775.734
6.003.534
6.183.640
6.303.711
6.423.781
9.391.815
9.673.570
9.861.406
10.049.242
1.509.610
1.554.898
1.585.090
1.615.282
B-4-10-ii
2.411.914
2.484.271
2.532.510
2.580.748
39
B-4-10-iii
3.687.530
3.798.156
3.871.907
3.945.657
40
B-4-11-i
3.646.298
3.755.687
3.828.613
3.901.539
41
B-4-11-ii
5.543.284
5.709.582
5.820.448
5.931.313
42
B-4-11-iii
5.970.309
6.149.418
6.268.824
6.388.231
43
B-4-12-i
3.199.377
3.295.358
3.359.346
3.423.333
44
B-4-12-ii
4.535.929
4.672.007
4.762.725
4.853.444
45
B-4-12-iii
8.815.985
9.080.465
9.256.785
9.433.104
46
B-4-13-i
2.894.297
2.981.126
3.039.012
3.096.897
47
B-4-13-ii
4.516.709
4.652.210
4.742.544
4.832.878
48
B-4-13-iii
6.855.406
7.061.068
7.198.176
7.335.284
49
B-4-14-i
2.894.297
2.981.126
3.039.012
3.096.897
50
B-4-14-ii
3.376.680
3.477.980
3.545.513
3.613.047
51
B-4-14-iii
4.504.830
4.639.975
4.730.072
4.820.168
52
C-4-10-i
2.818.461
2.903.015
2.959.384
3.015.753
53
C-4-10-ii
5.475.974
5.640.253
5.749.772
5.859.292
54
C-4-10-iii
LEUKEMIA AKUT BERAT
9.165.273
9.440.231
9.623.537
9.806.842
55
C-4-11-i
2.894.297
2.981.126
3.039.012
3.096.897
56
C-4-11-ii
3.859.062
3.974.834
4.052.015
4.129.197
57
C-4-11-iii
6.560.858
6.757.683
6.888.901
7.020.118
58
C-4-12-i
RADIOTERAPI RINGAN
1.929.531
1.987.417
2.026.008
2.064.598
59
C-4-12-ii
RADIOTERAPI SEDANG
5.312.582
5.471.959
5.578.211
5.684.463
60
C-4-12-iii
RADIOTERAPI BERAT
10.785.606
11.109.174
11.324.886
11.540.598
61
C-4-13-i
KEMOTERAPI RINGAN
1.929.531
1.987.417
2.026.008
2.064.598
62
C-4-13-ii
KEMOTERAPI SEDANG
3.859.062
3.974.834
4.052.015
4.129.197
63
C-4-13-iii
KEMOTERAPI BERAT
5.049.298
5.200.776
5.301.762
5.402.748

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT

PANCREAS RINGAN
PANCREAS SEDANG
PANCREAS BERAT
(RINGAN)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT
- 315 No
Kode
INA-CBG
64
C-4-14-i
65
C-4-14-ii
66
C-4-14-iii
67
D-1-10-i
68
D-1-10-ii
69
D-1-10-iii
70
D-1-11-i
71
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.502.086
2.577.148
2.627.190
2.677.232
3.656.208
3.765.894
3.839.018
3.912.142
5.573.783
5.740.996
5.852.472
5.963.947
20.532.500
21.148.475
21.559.125
21.969.775
31.272.572
32.210.749
32.836.201
33.461.652
42.382.880
43.654.367
44.502.024
45.349.682
4.220.279
4.346.887
4.431.293
4.515.698
D-1-11-ii
11.007.262
11.337.480
11.557.625
11.777.770
72
D-1-11-iii
15.595.481
16.063.345
16.375.255
16.687.165
73
D-1-20-i
5.198.494
5.354.448
5.458.418
5.562.388
74
D-1-20-ii
11.696.611
12.047.509
12.281.441
12.515.373
75
D-1-20-iii
21.143.560
21.777.867
22.200.738
22.623.609
76
D-4-10-i
1.853.433
1.909.036
1.946.105
1.983.174
77
D-4-10-ii
3.742.430
3.854.703
3.929.552
4.004.400
78
D-4-10-iii
4.823.828
4.968.543
5.065.019
5.161.496
79
D-4-11-i
4.220.849
4.347.475
4.431.892
4.516.309
80
D-4-11-ii
7.543.794
7.770.107
7.920.983
8.071.859
81
D-4-11-iii
10.327.905
10.637.742
10.844.300
11.050.859
82
D-4-12-i
2.474.164
2.548.388
2.597.872
2.647.355
83
D-4-12-ii
3.431.908
3.534.865
3.603.503
3.672.142
84
D-4-12-iii
5.269.697
5.427.787
5.533.181
5.638.575
85
D-4-13-i
1.929.531
1.987.417
2.026.008
2.064.598
86
D-4-13-ii
2.894.297
2.981.126
3.039.012
3.096.897
87
D-4-13-iii
3.376.680
3.477.980
3.545.513
3.613.047
88
D-4-14-i
2.324.850
2.394.595
2.441.092
2.487.589
89
D-4-14-ii
5.427.955
5.590.794
5.699.353
5.807.912
90
D-4-14-iii
6.474.800
6.669.044
6.798.540
6.928.036
91
E-1-01-i
4.625.290
4.764.049
4.856.555
4.949.060
92
E-1-01-ii
6.058.690
6.240.451
6.361.625
6.482.798
93
E-1-01-iii
13.732.161
14.144.126
14.418.769
14.693.413
94
E-1-10-i
4.712.923
4.854.311
4.948.569
5.042.828
95
E-1-10-ii
5.720.382
5.891.994
6.006.401
6.120.809
96
E-1-10-iii
12.056.882
12.418.588
12.659.726
12.900.864

RINGAN
SEDANG
BERAT
TULANG RINGAN
TULANG SEDANG
TULANG BERAT


RINGAN
SEDANG
BERAT
- 316 No
Kode
INA-CBG
97
E-1-20-i
98
E-1-20-ii
99
E-1-20-iii
100
E-4-10-i
101
E-4-10-ii
102
E-4-10-iii
103
E-4-11-i
104
E-4-11-ii
105
E-4-11-iii
106
E-4-12-i
107
E-4-12-ii
108
E-4-12-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.457.662
5.621.392
5.730.546
5.839.699
7.309.657
7.528.947
7.675.140
7.821.333
16.196.134
16.682.018
17.005.941
17.329.864
2.411.914
2.484.271
2.532.510
2.580.748
3.430.249
3.533.157
3.601.762
3.670.367
6.556.854
6.753.560
6.884.697
7.015.834
2.057.867
2.119.603
2.160.760
2.201.918
3.893.131
4.009.925
4.087.788
4.165.650
6.419.952
6.612.551
6.740.950
6.869.349
2.458.864
2.532.629
2.581.807
2.630.984
4.271.509
4.399.655
4.485.085
4.570.515
6.975.048
7.184.299
7.323.800
7.463.301
2.593.620
2.671.428
2.723.301
2.775.173
4.453.263
4.586.861
4.675.926
4.764.992
7.705.270
7.936.428
8.090.534
8.244.639

RINGAN
SEDANG
BERAT

RINGAN
SEDANG
BERAT
109
E-4-13-i
110
E-4-13-ii
111
E-4-13-iii
112
F-4-10-i
SCHIZOFRENIA RINGAN
3.171.191
3.266.326
3.329.750
3.393.174
113
F-4-10-ii
SCHIZOFRENIA SEDANG
3.521.709
3.627.361
3.697.795
3.768.229
114
F-4-10-iii
SCHIZOFRENIA BERAT
5.213.968
5.370.387
5.474.667
5.578.946
115
F-4-11-i
2.923.070
3.010.762
3.069.223
3.127.685
116
F-4-11-ii
3.405.654
3.507.823
3.575.936
3.644.050
117
F-4-11-iii
DEPRESI MAYOR BERAT
4.367.293
4.498.312
4.585.657
4.673.003
1.447.148
1.490.563
1.519.506
1.548.449
2.066.323
2.128.312
2.169.639
2.210.965
4.482.540
4.617.016
4.706.667
4.796.318

IMPULSE RINGAN
IMPULSE SEDANG
IMPULSE BERAT
118
F-4-12-i
119
F-4-12-ii
120
F-4-12-iii
121
F-4-13-i
2.362.284
2.433.153
2.480.399
2.527.644
122
F-4-13-ii
3.128.272
3.222.120
3.284.685
3.347.251
123
F-4-13-iii
4.033.507
4.154.512
4.235.182
4.315.852
124
F-4-14-i
DEPRESI RINGAN
1.653.599
1.703.207
1.736.279
1.769.351
125
F-4-14-ii
DEPRESI SEDANG
2.121.076
2.184.709
2.227.130
2.269.552
126
F-4-14-iii
DEPRESI BERAT
2.854.003
2.939.623
2.996.703
3.053.783
127
F-4-15-i
1.966.035
2.025.016
2.064.337
2.103.658
128
F-4-15-ii
2.894.297
2.981.126
3.039.012
3.096.897
129
F-4-15-iii
3.811.966
3.926.325
4.002.565
4.078.804
- 317 No
Kode
INA-CBG
130
F-4-16-i
131
F-4-16-ii
132
F-4-16-iii
133
F-4-17-i
134
F-4-17-ii
135
F-4-17-iii
136
F-4-18-i
137
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.234.455
4.361.489
4.446.178
4.530.867
4.922.448
5.070.122
5.168.571
5.267.020
6.570.647
6.767.766
6.899.179
7.030.592
977.686
1.007.016
1.026.570
1.046.124
2.865.503
2.951.468
3.008.779
3.066.089
3.057.281
3.149.000
3.210.145
3.271.291
3.670.283
3.780.392
3.853.797
3.927.203
F-4-18-ii
4.038.348
4.159.499
4.240.265
4.321.032
138
F-4-18-iii
6.225.466
6.412.230
6.536.739
6.661.248
139
F-4-19-i
2.814.761
2.899.204
2.955.499
3.011.794
140
F-4-19-ii
3.604.374
3.712.505
3.784.592
3.856.680
141
F-4-19-iii
4.487.493
4.622.118
4.711.868
4.801.618
142
G-1-01-i
8.948.725
9.217.187
9.396.162
9.575.136
143
G-1-01-ii
15.146.796
15.601.200
15.904.136
16.207.072
144
G-1-01-iii
29.322.505
30.202.181
30.788.631
31.375.081
145
G-1-10-i
4.465.865
4.599.841
4.689.159
4.778.476
146
G-1-10-ii
6.304.692
6.493.832
6.619.926
6.746.020
147
G-1-10-iii
7.472.406
7.696.578
7.846.027
7.995.475
148
G-1-11-i
5.151.509
5.306.054
5.409.084
5.512.115
149
G-1-11-ii
10.579.012
10.896.382
11.107.962
11.319.543
150
G-1-11-iii
22.151.489
22.816.034
23.259.063
23.702.093
151
G-1-12-i
4.006.356
4.126.547
4.206.674
4.286.801
152
G-1-12-ii
9.172.154
9.447.318
9.630.761
9.814.204
153
G-1-12-iii
16.177.668
16.662.998
16.986.551
17.310.104
154
G-1-13-i
1.056.601
1.088.299
1.109.431
1.130.563
155
G-1-13-ii
2.837.914
2.923.052
2.979.810
3.036.568
156
G-1-13-iii
6.403.530
6.595.636
6.723.706
6.851.777
5.048.350
5.199.800
5.300.767
5.401.734
6.820.486
7.025.100
7.161.510
7.297.920
16.699.157
17.200.132
17.534.115
17.868.098

RINGAN
SEDANG
BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

RINGAN
SEDANG
BERAT
157
G-1-20-i
158
G-1-20-ii
159
G-1-20-iii
160
G-1-30-i
6.438.715
6.631.877
6.760.651
6.889.426
161
G-1-30-ii
16.805.665
17.309.835
17.645.948
17.982.061
162
G-1-30-iii
21.634.084
22.283.106
22.715.788
23.148.470
- 318 No
Kode
INA-CBG
163
G-4-10-i
164
G-4-10-ii
165
G-4-10-iii
166
G-4-11-i
167
G-4-11-ii
168
G-4-11-iii
169
G-4-12-i
170
G-4-12-ii
171
G-4-12-iii
172
G-4-13-i
173
G-4-13-ii
174
G-4-13-iii
175
G-4-14-i
176
G-4-14-ii
177
G-4-14-iii
178
G-4-15-i
179
G-4-15-ii
180
G-4-15-iii
181
G-4-16-i
182
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.894.297
2.981.126
3.039.012
3.096.897
3.376.680
3.477.980
3.545.513
3.613.047
5.158.630
5.313.389
5.416.561
5.519.734
5.865.388
6.041.349
6.158.657
6.275.965
6.803.850
7.007.965
7.144.042
7.280.119
9.971.159
10.270.294
10.469.717
10.669.140
3.571.566
3.678.713
3.750.144
3.821.575
4.500.173
4.635.178
4.725.181
4.815.185
6.535.965
6.732.044
6.862.763
6.993.483
1.987.195
2.046.811
2.086.555
2.126.299
3.376.680
3.477.980
3.545.513
3.613.047
3.991.715
4.111.466
4.191.300
4.271.135
3.634.284
3.743.312
3.815.998
3.888.684
5.979.623
6.159.012
6.278.604
6.398.197
7.486.624
7.711.223
7.860.956
8.010.688
3.719.795
3.831.389
3.905.785
3.980.181
4.494.815
4.629.659
4.719.555
4.809.452
5.554.365
5.720.996
5.832.083
5.943.170
2.411.914
2.484.271
2.532.510
2.580.748
G-4-16-ii
3.607.039
3.715.250
3.787.391
3.859.532
183
G-4-16-iii
6.546.132
6.742.516
6.873.438
7.004.361
184
G-4-17-i
3.446.846
3.550.251
3.619.188
3.688.125
185
G-4-17-ii
4.277.687
4.406.018
4.491.571
4.577.125
186
G-4-17-iii
7.169.439
7.384.522
7.527.911
7.671.299
187
G-4-18-i
2.894.297
2.981.126
3.039.012
3.096.897
188
G-4-18-ii
4.149.921
4.274.418
4.357.417
4.440.415
189
G-4-18-iii
4.396.418
4.528.311
4.616.239
4.704.167
190
G-4-19-i
2.411.914
2.484.271
2.532.510
2.580.748
191
G-4-19-ii
4.888.068
5.034.710
5.132.471
5.230.233

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
DEGENERATIF RINGAN
DEGENERATIF SEDANG
DEGENERATIF BERAT
RINGAN
SEDANG
BERAT
TRAUMATIK RINGAN
TRAUMATIK SEDANG
TRAUMATIK BERAT
DENGAN INFARK BERAT
TANPA INFARK RINGAN
TANPA INFARK SEDANG
TANPA INFARK BERAT

PERIFER RINGAN
PERIFER SEDANG
PERIFER BERAT
PERSARAFAN RINGAN
PERSARAFAN SEDANG
PERSARAFAN BERAT
SEDANG
- 319 No
Kode
INA-CBG
192
G-4-19-iii
193
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

7.291.446
7.510.189
7.656.018
7.801.847
G-4-20-i
1.688.340
1.738.990
1.772.757
1.806.524
194
G-4-20-ii
2.397.444
2.469.368
2.517.317
2.565.265
195
G-4-20-iii
4.088.204
4.210.850
4.292.614
4.374.378
196
G-4-21-i
1.956.400
2.015.092
2.054.220
2.093.348
197
G-4-21-ii
4.051.899
4.173.456
4.254.494
4.335.532
198
G-4-21-iii
4.773.615
4.916.824
5.012.296
5.107.768
199
G-4-22-i
1.929.531
1.987.417
2.026.008
2.064.598
200
G-4-22-ii
2.411.914
2.484.271
2.532.510
2.580.748
201
G-4-22-iii
2.767.096
2.850.109
2.905.451
2.960.793
202
G-4-23-i
1.929.531
1.987.417
2.026.008
2.064.598
203
G-4-23-ii
2.411.914
2.484.271
2.532.510
2.580.748
204
G-4-23-iii
3.447.660
3.551.090
3.620.043
3.688.996
205
G-4-24-i
1.929.531
1.987.417
2.026.008
2.064.598
206
G-4-24-ii
2.411.914
2.484.271
2.532.510
2.580.748
207
G-4-24-iii
TRAUMA KEPALA BERAT
5.068.376
5.220.427
5.321.795
5.423.162
208
G-4-25-i
GEGAR OTAK RINGAN
1.833.431
1.888.434
1.925.103
1.961.772
209
G-4-25-ii
GEGAR OTAK SEDANG
2.308.330
2.377.580
2.423.747
2.469.913
210
G-4-25-iii
GEGAR OTAK BERAT
3.011.733
3.102.085
3.162.319
3.222.554
211
G-4-26-i
2.894.297
2.981.126
3.039.012
3.096.897
212
G-4-26-ii
3.376.680
3.477.980
3.545.513
3.613.047
213
G-4-26-iii
6.445.609
6.638.977
6.767.889
6.896.801
214
H-1-20-i
3.072.797
3.164.981
3.226.437
3.287.893
215
H-1-20-ii
PROSEDUR EKTRAOKULER DAN MATA

SEDANG
5.603.593
5.771.700
5.883.772
5.995.844
216
H-1-20-iii
7.620.536
7.849.152
8.001.563
8.153.973
217
H-1-30-i
3.008.561
3.098.817
3.158.989
3.219.160
218
H-1-30-ii
3.429.759
3.532.652
3.601.247
3.669.842
219
H-1-30-iii
5.722.429
5.894.102
6.008.551
6.122.999
220
H-4-10-i
3.554.935
3.661.583
3.732.682
3.803.780
221
H-4-10-ii
5.924.891
6.102.638
6.221.136
6.339.634
222
H-4-10-iii
9.659.323
9.949.103
10.142.289
10.335.475
223
H-4-11-i
2.369.957
2.441.055
2.488.454
2.535.854
224
H-4-11-ii
2.704.571
2.785.708
2.839.799
2.893.891
225
H-4-11-iii
3.867.283
3.983.302
4.060.647
4.137.993

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)

RINGAN
SEDANG
- 320 No
Kode
INA-CBG
226
H-4-12-i
227
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.029.336
3.120.216
3.180.803
3.241.390
H-4-12-ii
4.103.434
4.226.537
4.308.606
4.390.675
228
H-4-12-iii
6.846.300
7.051.689
7.188.615
7.325.541
229
I-1-01-i
41.627.323
42.876.143
43.708.689
44.541.235
230
I-1-01-ii
42.543.341
43.819.641
44.670.508
45.521.375
231
I-1-01-iii
67.153.848
69.168.463
70.511.540
71.854.617
232
I-1-02-i
23.094.599
23.787.437
24.249.329
24.711.221
233
I-1-02-ii
29.792.033
30.685.794
31.281.634
31.877.475
234
I-1-02-iii
36.720.412
37.822.025
38.556.433
39.290.841
235
I-1-03-i
14.222.476
14.649.150
14.933.599
15.218.049
236
I-1-03-ii
19.494.351
20.079.182
20.469.069
20.858.956
237
I-1-03-iii
28.591.715
29.449.467
30.021.301
30.593.135
238
I-1-04-i
17.351.004
17.871.534
18.218.554
18.565.574
239
I-1-04-ii
22.287.672
22.956.302
23.402.056
23.847.809
240
I-1-04-iii
47.512.689
48.938.070
49.888.324
50.838.578
241
I-1-05-i
30.566.381
31.483.372
32.094.700
32.706.028
242
I-1-05-ii
36.679.657
37.780.047
38.513.640
39.247.233
243
I-1-05-iii
50.470.977
51.985.106
52.994.526
54.003.945
244
I-1-06-i
14.408.314
14.840.563
15.128.730
15.416.896
245
I-1-06-ii
21.745.566
22.397.933
22.832.844
23.267.756
246
I-1-06-iii
27.994.318
28.834.147
29.394.034
29.953.920
18.948.024
19.516.465
19.895.425
20.274.386
23.376.237
24.077.524
24.545.049
25.012.573
25.503.322
26.268.422
26.778.488
27.288.555
3.604.376
3.712.507
3.784.595
3.856.683
4.007.706
4.127.937
4.208.091
4.288.245
5.333.035
5.493.026
5.599.687
5.706.347
11.046.799
11.378.203
11.599.139
11.820.075
15.327.949
15.787.788
16.094.347
16.400.906
247
I-1-07-i
248
I-1-07-ii
249
I-1-07-iii
250
I-1-11-i
251
I-1-11-ii
252
I-1-11-iii
253
I-1-12-i
254
I-1-12-ii

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
KATETERISASI RINGAN
KATETERISASI SEDANG
KATETERISASI BERAT
RINGAN
SEDANG
BERAT

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
- 321 No
Kode
INA-CBG
255
I-1-12-iii
256
I-1-13-i
257
I-1-13-ii
258
I-1-13-iii
259
I-1-14-i
260
I-1-14-ii
261
I-1-14-iii
262
I-1-15-i
263
I-1-15-ii
264
I-1-15-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
21.378.871
22.020.237
22.447.815
22.875.392
6.498.117
6.693.061
6.823.023
6.952.985
7.560.161
7.786.966
7.938.169
8.089.372
13.781.668
14.195.118
14.470.751
14.746.385
23.773.852
24.487.067
24.962.544
25.438.021
29.547.502
30.433.927
31.024.877
31.615.827
38.717.416
39.878.938
40.653.287
41.427.635
4.658.535
4.798.291
4.891.462
4.984.632
13.646.046
14.055.427
14.328.348
14.601.269
70.633.971
72.752.990
74.165.669
75.578.349
10.188.794
10.494.457
10.698.233
10.902.009
26.490.863
27.285.589
27.815.407
28.345.224
30.556.561
31.473.258
32.084.389
32.695.520
3.267.628
3.365.657
3.431.009
3.496.362
6.768.442
6.971.496
7.106.864
7.242.233
39.239.311
40.416.491
41.201.277
41.986.063
3.898.870
4.015.836
4.093.814
4.171.791
7.017.966
7.228.505
7.368.864
7.509.224
9.357.289
9.638.007
9.825.153
10.012.299
11.559.239
11.906.017
12.137.201
12.368.386
24.045.553
24.766.920
25.247.831
25.728.742
37.261.874
38.379.730
39.124.968
39.870.205
15.544.571
16.010.908
16.321.800
16.632.691
21.588.070
22.235.712
22.667.474
23.099.235
27.050.842
27.862.367
28.403.384
28.944.401

KOMPLEKS BERAT
KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

DARAH VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
265
I-1-16-i
266
I-1-16-ii
267
I-1-16-iii
268
I-1-17-i
269
I-1-17-ii
270
I-1-17-iii
271
I-1-20-i
272
I-1-20-ii
273
I-1-20-iii
274
I-1-30-i
275
I-1-30-ii
276
I-1-30-iii
277
I-1-40-i
278
I-1-40-ii
279
I-1-40-iii
280
I-4-10-i
4.520.813
4.656.437
4.746.854
4.837.270
281
I-4-10-ii
7.138.445
7.352.598
7.495.367
7.638.136
282
I-4-10-iii
10.297.829
10.606.764
10.812.721
11.018.677
283
I-4-11-i
5.360.502
5.521.317
5.628.527
5.735.737
- 322 No
Kode
INA-CBG
Deskripsi (INA-CBG)
284
I-4-11-ii
285
I-4-11-iii
286
I-4-12-i
287
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
6.633.642
6.832.651
6.965.324
7.097.997
11.739.972
12.092.171
12.326.970
12.561.770
4.695.243
4.836.100
4.930.005
5.023.909
I-4-12-ii
6.700.098
6.901.101
7.035.103
7.169.105
288
I-4-12-iii
8.128.161
8.372.006
8.534.569
8.697.132
289
I-4-13-i
4.217.618
4.344.147
4.428.499
4.512.852
290
I-4-13-ii
6.127.339
6.311.159
6.433.706
6.556.253
291
I-4-13-iii
12.541.952
12.918.211
13.169.050
13.419.889
292
I-4-14-i
2.622.969
2.701.658
2.754.118
2.806.577
293
I-4-14-ii
3.069.262
3.161.340
3.222.725
3.284.110
294
I-4-14-iii
4.756.335
4.899.025
4.994.151
5.089.278
295
I-4-15-i
3.859.062
3.974.834
4.052.015
4.129.197
296
I-4-15-ii
5.524.439
5.690.172
5.800.661
5.911.149
297
I-4-15-iii
6.296.531
6.485.427
6.611.358
6.737.288
298
I-4-16-i
2.894.297
2.981.126
3.039.012
3.096.897
299
I-4-16-ii
4.690.658
4.831.378
4.925.191
5.019.004
300
I-4-16-iii
5.909.396
6.086.678
6.204.866
6.323.054
301
I-4-17-i
HIPERTENSI RINGAN
2.590.336
2.668.046
2.719.852
2.771.659
302
I-4-17-ii
HIPERTENSI SEDANG
3.668.173
3.778.218
3.851.582
3.924.945
303
I-4-17-iii
HIPERTENSI BERAT
4.462.508
4.596.383
4.685.633
4.774.883
304
I-4-18-i
3.814.820
3.929.265
4.005.561
4.081.858
305
I-4-18-ii
5.844.049
6.019.371
6.136.252
6.253.133
306
I-4-18-iii
7.878.715
8.115.077
8.272.651
8.430.225
307
I-4-19-i
2.985.597
3.075.165
3.134.877
3.194.589
308
I-4-19-ii
4.890.314
5.037.024
5.134.830
5.232.636
309
I-4-19-iii
5.829.210
6.004.086
6.120.671
6.237.255
310
I-4-20-i
3.623.445
3.732.148
3.804.617
3.877.086
311
I-4-20-ii
4.174.479
4.299.713
4.383.203
4.466.693
312
I-4-20-iii
5.540.228
5.706.435
5.817.240
5.928.044
313
I-4-21-i
4.818.595
4.963.153
5.059.525
5.155.897
314
I-4-21-ii
6.010.885
6.191.211
6.311.429
6.431.647
315
I-4-21-iii
8.200.121
8.446.125
8.610.127
8.774.130
316
I-4-22-i
3.135.488
3.229.553
3.292.263
3.354.972

VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT


RINGAN
SEDANG
KONGENITAL BERAT
RINGAN
SEDANG
BERAT
- 323 No
Kode
INA-CBG
317
I-4-22-ii
318
I-4-22-iii
319
I-4-23-i
320
I-4-23-ii
321
I-4-23-iii
322
I-4-24-i
323
I-4-24-ii
324
I-4-24-iii
325
J-1-01-i
326
J-1-01-ii
327
J-1-01-iii
328
J-1-02-i
329
J-1-02-ii
330
J-1-02-iii
331
J-1-10-i
332
J-1-10-ii
333
J-1-10-iii
334
J-1-20-i
335
J-1-20-ii
336
J-1-20-iii
337
J-1-30-i
338
J-1-30-ii
339
J-1-30-iii
340
J-4-10-i
341
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.613.021
3.721.411
3.793.672
3.865.932
5.271.299
5.429.438
5.534.864
5.640.290
2.375.309
2.446.568
2.494.075
2.541.581
2.916.332
3.003.822
3.062.149
3.120.475
5.698.247
5.869.195
5.983.160
6.097.125
2.833.058
2.918.050
2.974.711
3.031.372
7.073.362
7.285.562
7.427.030
7.568.497
8.942.988
9.211.278
9.390.137
9.568.997
23.266.717
23.964.719
24.430.053
24.895.388
25.342.657
26.102.936
26.609.789
27.116.642
41.660.116
42.909.919
43.743.121
44.576.324
11.667.726
12.017.758
12.251.113
12.484.467
12.499.244
12.874.221
13.124.206
13.374.191
18.470.321
19.024.430
19.393.837
19.763.243
4.552.916
4.689.503
4.780.561
4.871.620
10.996.946
11.326.854
11.546.793
11.766.732
19.471.444
20.055.587
20.445.016
20.834.445
3.935.176
4.053.231
4.131.935
4.210.638
5.723.403
5.895.105
6.009.573
6.124.041
8.606.230
8.864.417
9.036.541
9.208.666
2.653.706
2.733.318
2.786.392
2.839.466
12.996.234
13.386.121
13.646.046
13.905.971
39.196.071
40.371.954
41.155.875
41.939.796
3.062.731
3.154.613
3.215.868
3.277.123
J-4-10-ii
4.379.338
4.510.718
4.598.305
4.685.892
342
J-4-10-iii
6.625.285
6.824.043
6.956.549
7.089.055
343
J-4-11-i
1.932.194
1.990.160
2.028.804
2.067.447
344
J-4-11-ii
2.689.570
2.770.257
2.824.048
2.877.840
345
J-4-11-iii
3.854.222
3.969.849
4.046.933
4.124.018
346
J-4-12-i
EMBOLI PARU RINGAN
2.954.826
3.043.471
3.102.568
3.161.664
347
J-4-12-ii
EMBOLI PARU SEDANG
3.826.399
3.941.191
4.017.719
4.094.247

RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
- 324 No
Kode
INA-CBG
348
J-4-12-iii
349
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
EMBOLI PARU BERAT
5.109.769
5.263.062
5.365.258
5.467.453
J-4-13-i
4.551.554
4.688.101
4.779.132
4.870.163
350
J-4-13-ii
6.690.785
6.891.509
7.025.324
7.159.140
351
J-4-13-iii
10.878.215
11.204.562
11.422.126
11.639.690
352
J-4-14-i
TUMOR PARU RINGAN
3.101.741
3.194.793
3.256.828
3.318.862
353
J-4-14-ii
TUMOR PARU SEDANG
5.195.840
5.351.715
5.455.632
5.559.549
354
J-4-14-iii
TUMOR PARU BERAT
6.177.590
6.362.917
6.486.469
6.610.021
355
J-4-15-i
2.894.297
2.981.126
3.039.012
3.096.897
356
J-4-15-ii
5.237.654
5.394.783
5.499.537
5.604.290
357
J-4-15-iii
6.544.344
6.740.674
6.871.561
7.002.448
358
J-4-16-i
2.411.914
2.484.271
2.532.510
2.580.748
359
J-4-16-ii
3.376.680
3.477.980
3.545.513
3.613.047
360
J-4-16-iii
6.091.175
6.273.910
6.395.733
6.517.557
361
J-4-17-i
3.012.107
3.102.471
3.162.713
3.222.955
362
J-4-17-ii
4.069.875
4.191.971
4.273.369
4.354.766
363
J-4-17-iii
5.320.998
5.480.628
5.587.048
5.693.468
364
J-4-18-i
2.710.044
2.791.346
2.845.547
2.899.747
365
J-4-18-ii
3.773.467
3.886.671
3.962.140
4.037.610
366
J-4-18-iii
3.913.919
4.031.337
4.109.615
4.187.894
367
J-4-19-i
3.376.680
3.477.980
3.545.513
3.613.047
368
J-4-19-ii
3.859.062
3.974.834
4.052.015
4.129.197
369
J-4-19-iii
6.045.674
6.227.044
6.347.957
6.468.871
370
J-4-20-i
3.376.680
3.477.980
3.545.513
3.613.047
371
J-4-20-ii
4.118.925
4.242.493
4.324.871
4.407.250
372
J-4-20-iii
9.307.285
9.586.504
9.772.650
9.958.795
373
J-4-21-i
1.929.531
1.987.417
2.026.008
2.064.598
374
J-4-21-ii
4.760.506
4.903.321
4.998.531
5.093.741
375
J-4-21-iii
6.790.038
6.993.739
7.129.540
7.265.341
376
K-1-10-i
5.198.494
5.354.448
5.458.418
5.562.388
377
K-1-10-ii
7.254.839
7.472.485
7.617.581
7.762.678
378
K-1-10-iii
8.496.666
8.751.566
8.921.499
9.091.433
379
K-1-11-i
4.469.905
4.604.002
4.693.400
4.782.798
380
K-1-11-ii
5.868.446
6.044.499
6.161.868
6.279.237

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT

USUS BESAR (RINGAN)
USUS BESAR (SEDANG)
USUS BESAR (BERAT)
PROSEDUR ADHESIOLISIS PERITONEAL
RINGAN
SEDANG
- 325 No
Kode
INA-CBG
381
K-1-11-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
14.892.960
15.339.749
15.637.608
15.935.468
2.404.467
2.476.601
2.524.690
2.572.779
3.133.764
3.227.777
3.290.452
3.353.127
6.233.715
6.420.727
6.545.401
6.670.076
382
K-1-12-i
383
K-1-12-ii
384
K-1-12-iii
385
K-1-13-i
2.731.145
2.813.079
2.867.702
2.922.325
386
K-1-13-ii
4.770.525
4.913.641
5.009.052
5.104.462
387
K-1-13-iii
5.101.905
5.254.962
5.357.000
5.459.038
4.413.691
4.546.102
4.634.376
4.722.650
5.184.381
5.339.912
5.443.600
5.547.287
12.765.448
13.148.412
13.403.721
13.659.030

RINGAN
SEDANG
BERAT
388
K-1-14-i
389
K-1-14-ii
390
K-1-14-iii
391
K-1-20-i
8.563.856
8.820.772
8.992.049
9.163.326
392
K-1-20-ii
11.952.885
12.311.471
12.550.529
12.789.587
393
K-1-20-iii
25.531.926
26.297.884
26.808.523
27.319.161
394
K-1-30-i
5.637.156
5.806.271
5.919.014
6.031.757
395
K-1-30-ii
10.396.987
10.708.897
10.916.837
11.124.776
396
K-1-30-iii
16.191.974
16.677.733
17.001.573
17.325.412
397
K-1-40-i
5.663.204
5.833.100
5.946.364
6.059.628
398
K-1-40-ii
6.231.794
6.418.747
6.543.383
6.668.019
399
K-1-40-iii
10.334.830
10.644.874
10.851.571
11.058.268
400
K-1-50-i
4.319.658
4.449.248
4.535.641
4.622.034
401
K-1-50-ii
5.594.161
5.761.986
5.873.869
5.985.753
402
K-1-50-iii
PROSEDUR ANAL BERAT
7.942.221
8.180.488
8.339.332
8.498.177
403
K-4-10-i
3.271.830
3.369.985
3.435.422
3.500.859
404
K-4-10-ii
3.914.937
4.032.385
4.110.684
4.188.983
405
K-4-10-iii
16.211.704
16.698.056
17.022.290
17.346.524
406
K-4-11-i
1.929.531
1.987.417
2.026.008
2.064.598
407
K-4-11-ii
2.894.297
2.981.126
3.039.012
3.096.897
408
K-4-11-iii
5.259.980
5.417.779
5.522.979
5.628.179
409
K-4-12-i
1.929.531
1.987.417
2.026.008
2.064.598
410
K-4-12-ii
2.882.690
2.969.170
3.026.824
3.084.478
411
K-4-12-iii
6.918.250
7.125.797
7.264.162
7.402.527
412
K-4-13-i

(RINGAN)
2.894.297
2.981.126
3.039.012
3.096.897

(RINGAN)
(SEDANG)
(BERAT)
- 326 No
Kode
INA-CBG
413
K-4-13-ii
414
K-4-13-iii
415
K-4-14-i
416
K-4-14-ii
417
K-4-14-iii
418
K-4-15-i
419
K-4-15-ii
420
K-4-15-iii
421
K-4-16-i
422
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.748.827
3.861.292
3.936.268
4.011.245
6.131.440
6.315.383
6.438.012
6.560.641
2.411.914
2.484.271
2.532.510
2.580.748
3.264.274
3.362.202
3.427.487
3.492.773
4.937.525
5.085.651
5.184.402
5.283.152
2.411.914
2.484.271
2.532.510
2.580.748
4.535.056
4.671.108
4.761.809
4.852.510
6.452.568
6.646.146
6.775.197
6.904.248
2.411.914
2.484.271
2.532.510
2.580.748
K-4-16-ii
2.894.297
2.981.126
3.039.012
3.096.897
423
K-4-16-iii
3.532.865
3.638.851
3.709.508
3.780.166
424
K-4-17-i
1.929.531
1.987.417
2.026.008
2.064.598
425
K-4-17-ii
2.815.222
2.899.679
2.955.983
3.012.288
426
K-4-17-iii
3.746.773
3.859.176
3.934.112
4.009.047
427
K-4-18-i
1.929.531
1.987.417
2.026.008
2.064.598
428
K-4-18-ii
2.995.433
3.085.296
3.145.204
3.205.113
429
K-4-18-iii
3.543.582
3.649.889
3.720.761
3.791.633
430
L-1-20-i
19.745.377
20.337.739
20.732.646
21.127.554
431
L-1-20-ii
20.540.636
21.156.855
21.567.667
21.978.480
432
L-1-20-iii
31.470.625
32.414.744
33.044.156
33.673.569
433
L-1-30-i
8.955.922
9.224.599
9.403.718
9.582.836
434
L-1-30-ii
12.972.682
13.361.862
13.621.316
13.880.769
435
L-1-30-iii
13.682.131
14.092.595
14.366.238
14.639.881
436
L-1-40-i
3.616.141
3.724.625
3.796.948
3.869.270
437
L-1-40-ii
8.138.847
8.383.013
8.545.790
8.708.567
438
L-1-40-iii
13.793.195
14.206.991
14.482.855
14.758.719
439
L-1-50-i
6.498.117
6.693.061
6.823.023
6.952.985
440
L-1-50-ii
11.696.611
12.047.509
12.281.441
12.515.373
441
L-1-50-iii
14.142.857
14.567.143
14.850.000
15.132.857
442
L-4-10-i
2.894.297
2.981.126
3.039.012
3.096.897
443
L-4-10-ii
3.376.680
3.477.980
3.545.513
3.613.047

(SEDANG)
RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
- 327 No
Kode
INA-CBG
444
L-4-10-iii
445
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
6.830.734
7.035.656
7.172.271
7.308.885
L-4-11-i
2.737.478
2.819.602
2.874.351
2.929.101
446
L-4-11-ii
3.750.296
3.862.805
3.937.811
4.012.817
447
L-4-11-iii
10.170.335
10.475.445
10.678.852
10.882.258
448
L-4-12-i
2.894.297
2.981.126
3.039.012
3.096.897
449
L-4-12-ii
4.246.605
4.374.003
4.458.935
4.543.867
450
L-4-12-iii
7.121.054
7.334.685
7.477.106
7.619.528
451
L-4-13-i
1.816.663
1.871.163
1.907.496
1.943.829
452
L-4-13-ii
2.094.719
2.157.561
2.199.455
2.241.350
453
L-4-13-iii
3.142.242
3.236.509
3.299.354
3.362.199
454
L-4-14-i
1.929.531
1.987.417
2.026.008
2.064.598
455
L-4-14-ii
2.894.297
2.981.126
3.039.012
3.096.897
456
L-4-14-iii
4.525.285
4.661.044
4.751.549
4.842.055
457
M-1-01-i
9.407.216
9.689.433
9.877.577
10.065.721
458
M-1-01-ii
10.499.975
10.814.974
11.024.974
11.234.973
459
M-1-01-iii
14.749.620
15.192.109
15.487.101
15.782.094
460
M-1-02-i
6.662.708
6.862.590
6.995.844
7.129.098
461
M-1-02-ii
10.938.900
11.267.067
11.485.845
11.704.623
462
M-1-02-iii
19.809.847
20.404.142
20.800.339
21.196.536
463
M-1-03-i
16.895.104
17.401.957
17.739.860
18.077.762
464
M-1-03-ii
19.772.213
20.365.379
20.760.824
21.156.268
465
M-1-03-iii
20.144.163
20.748.488
21.151.371
21.554.254
466
M-1-04-i
4.395.189
4.527.045
4.614.948
4.702.852
467
M-1-04-ii
5.634.587
5.803.624
5.916.316
6.029.008
468
M-1-04-iii
7.050.623
7.262.142
7.403.154
7.544.167
469
M-1-05-i
6.846.860
7.052.266
7.189.203
7.326.141
470
M-1-05-ii
7.913.136
8.150.530
8.308.793
8.467.055
471
M-1-05-iii
13.478.226
13.882.572
14.152.137
14.421.701
472
M-1-07-i
7.557.975
7.784.715
7.935.874
8.087.034
473
M-1-07-ii
10.125.325
10.429.085
10.631.592
10.834.098
474
M-1-07-iii
20.626.248
21.245.035
21.657.560
22.070.085
475
M-1-10-i
4.723.589
4.865.297
4.959.769
5.054.241


TULANG WAJAH RINGAN
- 328 No
Kode
INA-CBG
476
M-1-10-ii
477
M-1-10-iii
478
M-1-20-i
479
M-1-20-ii
480
M-1-20-iii
481
M-1-30-i
482
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
17.545.994
18.072.374
18.423.294
18.774.214
21.462.095
22.105.958
22.535.200
22.964.442
4.672.850
4.813.036
4.906.493
4.999.950
6.670.074
6.870.177
7.003.578
7.136.980
12.965.171
13.354.126
13.613.429
13.872.733
2.795.063
2.878.915
2.934.816
2.990.717
M-1-30-ii
5.775.311
5.948.571
6.064.077
6.179.583
483
M-1-30-iii
PROSEDUR KAKI BERAT
8.615.547
8.874.013
9.046.324
9.218.635
484
M-1-40-i
2.824.194
2.908.920
2.965.404
3.021.888
485
M-1-40-ii
5.198.494
5.354.448
5.458.418
5.562.388
486
M-1-40-iii
9.097.364
9.370.285
9.552.232
9.734.179
487
M-1-50-i
3.740.289
3.852.498
3.927.304
4.002.109
488
M-1-50-ii
7.529.290
7.755.169
7.905.754
8.056.340
489
M-1-50-iii
10.396.987
10.708.897
10.916.837
11.124.776
490
M-1-60-i
2.822.738
2.907.420
2.963.875
3.020.330
491
M-1-60-ii
5.651.140
5.820.674
5.933.697
6.046.720
492
M-1-60-iii
9.834.982
10.130.032
10.326.732
10.523.431
493
M-1-70-i
3.781.334
3.894.774
3.970.401
4.046.027
494
M-1-70-ii
7.715.794
7.947.268
8.101.584
8.255.900
495
M-1-70-iii
12.438.792
12.811.956
13.060.732
13.309.508
496
M-1-80-i
3.046.732
3.138.134
3.199.068
3.260.003
497
M-1-80-ii
4.606.036
4.744.217
4.836.337
4.928.458
498
M-1-80-iii
10.604.287
10.922.416
11.134.501
11.346.587
499
M-4-10-i
1.929.531
1.987.417
2.026.008
2.064.598
500
M-4-10-ii
2.943.980
3.032.299
3.091.179
3.150.059
501
M-4-10-iii
FRAKTUR FEMUR BERAT
6.251.386
6.438.927
6.563.955
6.688.983
502
M-4-11-i
2.553.636
2.630.245
2.681.318
2.732.391
503
M-4-11-ii
5.858.422
6.034.175
6.151.343
6.268.512
504
M-4-11-iii
10.398.562
10.710.519
10.918.490
11.126.461
505
M-4-12-i
1.929.531
1.987.417
2.026.008
2.064.598
506
M-4-12-ii
3.510.780
3.616.103
3.686.319
3.756.534

TULANG WAJAH SEDANG
TULANG WAJAH BERAT
PROSEDUR PAHA DAN SENDI PANGGUL
SELAIN SENDI MAYOR RINGAN
SELAIN SENDI MAYOR SEDANG
SELAIN SENDI MAYOR BERAT

RINGAN
SEDANG
BERAT

SELAIN KAKI (BERAT)

PANGGUL RINGAN
PANGGUL SEDANG
PANGGUL BERAT
PELVIS RINGAN
PELVIS SEDANG
- 329 No
Kode
INA-CBG
507
M-4-12-iii
508
M-4-13-i
509
M-4-13-ii
510
M-4-13-iii
511
M-4-14-i
512
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
7.031.173
7.242.108
7.382.732
7.523.355
3.562.085
3.668.947
3.740.189
3.811.431
4.823.828
4.968.543
5.065.019
5.161.496
10.596.310
10.914.199
11.126.126
11.338.052
3.859.062
3.974.834
4.052.015
4.129.197
M-4-14-ii
5.010.098
5.160.401
5.260.602
5.360.804
513
M-4-14-iii
OSTEOMIELITIS BERAT
7.504.586
7.729.724
7.879.815
8.029.907
514
M-4-15-i
2.407.642
2.479.871
2.528.024
2.576.177
515
M-4-15-ii
3.210.392
3.306.704
3.370.912
3.435.120
516
M-4-15-iii
8.200.507
8.446.523
8.610.533
8.774.543
517
M-4-16-i
2.411.914
2.484.271
2.532.510
2.580.748
518
M-4-16-ii
3.859.062
3.974.834
4.052.015
4.129.197
519
M-4-16-iii
7.175.650
7.390.920
7.534.433
7.677.946
520
M-4-17-i
2.411.914
2.484.271
2.532.510
2.580.748
521
M-4-17-ii
3.376.680
3.477.980
3.545.513
3.613.047
522
M-4-17-iii
4.715.712
4.857.184
4.951.498
5.045.812
523
M-4-18-i
2.827.138
2.911.952
2.968.495
3.025.037
524
M-4-18-ii
3.859.062
3.974.834
4.052.015
4.129.197
525
M-4-18-iii
4.794.661
4.938.500
5.034.394
5.130.287
526
M-4-19-i
2.102.015
2.165.076
2.207.116
2.249.156
527
M-4-19-ii
3.540.467
3.646.681
3.717.490
3.788.299
528
M-4-19-iii
6.914.793
7.122.237
7.260.533
7.398.829
529
M-4-20-i
1.929.531
1.987.417
2.026.008
2.064.598
530
M-4-20-ii
2.894.297
2.981.126
3.039.012
3.096.897
531
M-4-20-iii
3.207.563
3.303.790
3.367.941
3.432.092
532
M-4-21-i
1.929.531
1.987.417
2.026.008
2.064.598
533
M-4-21-ii
2.518.523
2.594.079
2.644.450
2.694.820
534
M-4-21-iii
6.139.097
6.323.270
6.446.052
6.568.834
535
N-1-01-i
5.220.789
5.377.413
5.481.829
5.586.245
536
N-1-01-ii
7.061.000
7.272.830
7.414.050
7.555.270
537
N-1-01-iii
14.971.420
15.420.563
15.719.991
16.019.419

PELVIS BERAT

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
RINGAN
SEDANG
BERAT
ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
- 330 No
Kode
INA-CBG
538
N-1-11-i
539
N-1-11-ii
540
N-1-11-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
7.202.482
7.418.556
7.562.606
7.706.656
9.741.194
10.033.430
10.228.254
10.423.078
20.654.230
21.273.857
21.686.941
22.100.026
3.898.870
4.015.836
4.093.814
4.171.791
9.070.446
9.342.559
9.523.968
9.705.377
16.531.452
17.027.396
17.358.025
17.688.654
541
N-1-12-i
542
N-1-12-ii
543
N-1-12-iii
544
N-1-20-i
5.278.762
5.437.125
5.542.700
5.648.276
545
N-1-20-ii
10.465.909
10.779.886
10.989.205
11.198.523
546
N-1-20-iii
11.972.051
12.331.213
12.570.654
12.810.095
547
N-1-30-i
6.280.020
6.468.420
6.594.020
6.719.621
548
N-1-30-ii
9.543.273
9.829.571
10.020.437
10.211.302
549
N-1-30-iii
10.985.881
11.315.457
11.535.175
11.754.892
550
N-1-40-i
5.658.912
5.828.680
5.941.858
6.055.036
551
N-1-40-ii
7.670.857
7.900.983
8.054.400
8.207.817
552
N-1-40-iii
8.921.429
9.189.072
9.367.500
9.545.929
553
N-4-10-i
2.411.914
2.484.271
2.532.510
2.580.748
554
N-4-10-ii
3.229.620
3.326.509
3.391.101
3.455.694
555
N-4-10-iii
7.069.057
7.281.129
7.422.510
7.563.891
556
N-4-11-i
1.847.051
1.902.463
1.939.404
1.976.345
557
N-4-11-ii
3.121.472
3.215.116
3.277.546
3.339.975
558
N-4-11-iii
3.617.871
3.726.407
3.798.764
3.871.122
559
N-4-12-i
1.929.531
1.987.417
2.026.008
2.064.598
560
N-4-12-ii
2.894.297
2.981.126
3.039.012
3.096.897
561
N-4-12-iii
4.805.484
4.949.648
5.045.758
5.141.868
562
N-4-13-i
BATU URIN RINGAN
2.545.645
2.622.014
2.672.927
2.723.840
563
N-4-13-ii
BATU URIN SEDANG
3.069.090
3.161.163
3.222.545
3.283.927
564
N-4-13-iii
BATU URIN BERAT
7.558.327
7.785.077
7.936.244
8.087.410
1.671.332
1.721.472
1.754.898
1.788.325
2.573.640
2.650.850
2.702.322
2.753.795
4.173.624
4.298.833
4.382.306
4.465.778
565
N-4-14-i
566
N-4-14-ii
567
N-4-14-iii

URIN BAWAH RINGAN
URIN BAWAH SEDANG
URIN BAWAH BERAT
RINGAN
SEDANG
BERAT
GINJAL RINGAN
GINJAL SEDANG
GINJAL BERAT

(RINGAN)
(SEDANG)
(BERAT)
- 331 No
Kode
INA-CBG
568
N-4-15-i
569
N-4-15-ii
570
N-4-15-iii
571
N-4-16-i
572
N-4-16-ii
573
N-4-16-iii
574
O-6-10-i
575
O-6-10-ii
576
O-6-10-iii
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
584
O-6-13-ii
585
O-6-13-iii
586
P-8-01-i
587
P-8-01-ii
588
P-8-01-iii
589
P-8-02-i
590
P-8-02-ii
591
P-8-02-iii
592
P-8-03-i
593
P-8-03-ii
594
P-8-03-iii
595
P-8-04-i
596
P-8-04-ii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.479.551
2.553.937
2.603.528
2.653.119
3.402.715
3.504.797
3.572.851
3.640.905
3.883.112
3.999.605
4.077.268
4.154.930
3.218.114
3.314.658
3.379.020
3.443.382
3.859.062
3.974.834
4.052.015
4.129.197
8.115.034
8.358.485
8.520.786
8.683.086
4.751.704
4.894.256
4.989.290
5.084.324
5.275.116
5.433.370
5.538.872
5.644.374
5.913.469
6.090.873
6.209.142
6.327.411
2.483.411
2.557.913
2.607.581
2.657.249
3.185.989
3.281.569
3.345.289
3.409.008
5.399.263
5.561.241
5.669.226
5.777.211
2.162.566
2.227.443
2.270.694
2.313.945
2.597.236
2.675.153
2.727.098
2.779.042
3.263.055
3.360.946
3.426.208
3.491.469
2.167.281
2.232.299
2.275.645
2.318.990
3.194.146
3.289.971
3.353.854
3.417.737
3.774.988
3.888.237
3.963.737
4.039.237
48.481.088
49.935.521
50.905.143
51.874.764
59.987.763
61.787.396
62.987.151
64.186.906
70.408.818
72.521.082
73.929.258
75.337.435
58.738.622
60.500.781
61.675.553
62.850.326
67.379.246
69.400.623
70.748.208
72.095.793
76.985.606
79.295.174
80.834.886
82.374.598
3.249.059
3.346.530
3.411.511
3.476.493
4.548.682
4.685.142
4.776.116
4.867.090
7.165.206
7.380.162
7.523.466
7.666.770
29.016.375
29.886.866
30.467.193
31.047.521
37.656.998
38.786.708
39.539.848
40.292.988

SALURAN URIN RINGAN
SALURAN URIN SEDANG
SALURAN URIN BERAT
RINGAN
SEDANG
BERAT
&KURET RINGAN
KURET SEDANG
KURET BERAT

- 332 No
Kode
INA-CBG
597
P-8-04-iii
598
P-8-05-i
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii
603
P-8-06-iii
604
P-8-07-i
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
614
P-8-11-ii
615
P-8-11-iii
616
P-8-12-i
617
P-8-12-ii
618
P-8-12-iii
619
P-8-13-i
620
P-8-13-ii
621
P-8-13-iii
622
P-8-14-i
623
P-8-14-ii
624
P-8-14-iii
Deskripsi (INA-CBG)
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
RINGAN
SEDANG
BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
53.990.657
55.610.377
56.690.190
57.770.003
15.778.164
16.251.509
16.567.072
16.882.635
22.363.420
23.034.323
23.481.591
23.928.859
32.949.497
33.937.982
34.596.972
35.255.962
2.599.247
2.677.224
2.729.209
2.781.194
6.540.386
6.736.598
6.867.405
6.998.213
12.165.864
12.530.840
12.774.157
13.017.475
4.548.682
4.685.142
4.776.116
4.867.090
12.753.409
13.136.012
13.391.080
13.646.148
16.895.104
17.401.957
17.739.860
18.077.762
3.296.347
3.395.237
3.461.164
3.527.091
4.679.628
4.820.017
4.913.610
5.007.202
6.606.198
6.804.384
6.936.508
7.068.632
2.045.050
2.106.401
2.147.302
2.188.203
2.962.552
3.051.429
3.110.680
3.169.931
5.816.363
5.990.854
6.107.181
6.223.509
5.759.730
5.932.521
6.047.716
6.162.911
12.262.306
12.630.176
12.875.422
13.120.668
12.519.204
12.894.780
13.145.164
13.395.548
2.717.289
2.798.808
2.853.154
2.907.500
4.224.913
4.351.660
4.436.159
4.520.657
4.984.504
5.134.039
5.233.729
5.333.419
1.404.442
1.446.575
1.474.664
1.502.752
2.598.908
2.676.875
2.728.854
2.780.832
3.886.945
4.003.553
4.081.292
4.159.031
2.566.061
2.643.043
2.694.364
2.745.685
5.239.170
5.396.345
5.501.128
5.605.912
5.747.350
5.919.770
6.034.717
6.149.664
- 333 No
Kode
INA-CBG
625
P-8-15-i
626
P-8-15-ii
627
P-8-15-iii
628
P-8-16-i
629
P-8-16-ii
630
P-8-16-iii
631
P-8-17-i
632
P-8-17-ii
633
P-8-17-iii
634
S-4-10-i
635
S-4-10-ii
636
S-4-10-iii
637
S-4-11-i
638
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.929.758
1.987.650
2.026.246
2.064.841
3.857.078
3.972.791
4.049.932
4.127.074
4.530.736
4.666.658
4.757.272
4.847.887
1.746.887
1.799.293
1.834.231
1.869.169
2.478.034
2.552.375
2.601.935
2.651.496
3.216.609
3.313.108
3.377.440
3.441.772
1.152.941
1.187.530
1.210.589
1.233.647
3.829.682
3.944.572
4.021.166
4.097.759
7.729.968
7.961.867
8.116.467
8.271.066
1.929.531
1.987.417
2.026.008
2.064.598
2.411.914
2.484.271
2.532.510
2.580.748
3.135.074
3.229.126
3.291.828
3.354.529
1.205.957
1.242.136
1.266.255
1.290.374
S-4-11-ii
1.835.489
1.890.554
1.927.264
1.963.974
639
S-4-11-iii
2.969.501
3.058.586
3.117.976
3.177.366
640
S-4-12-i
1.447.148
1.490.563
1.519.506
1.548.449
641
S-4-12-ii
1.929.531
1.987.417
2.026.008
2.064.598
642
S-4-12-iii
3.768.527
3.881.583
3.956.953
4.032.324
643
S-4-13-i
1.929.531
1.987.417
2.026.008
2.064.598
644
S-4-13-ii
3.410.978
3.513.308
3.581.527
3.649.747
645
S-4-13-iii
6.945.186
7.153.541
7.292.445
7.431.349
646
S-4-14-i
1.175.628
1.210.897
1.234.409
1.257.922
647
S-4-14-ii
2.497.428
2.572.351
2.622.299
2.672.248
648
S-4-14-iii
4.736.013
4.878.093
4.972.814
5.067.534
649
S-4-15-i
889.138
915.812
933.595
951.378
650
S-4-15-ii
1.678.107
1.728.450
1.762.012
1.795.574
651
S-4-15-iii
2.173.538
2.238.744
2.282.215
2.325.686
652
S-4-16-i
LUKA BAKAR RINGAN
3.376.680
3.477.980
3.545.513
3.613.047
653
S-4-16-ii
LUKA BAKAR SEDANG
4.768.971
4.912.041
5.007.420
5.102.799
654
S-4-16-iii
LUKA BAKAR BERAT
8.515.739
8.771.211
8.941.526
9.111.841
1.800.512
1.854.527
1.890.537
1.926.548
2.411.914
2.484.271
2.532.510
2.580.748
655
S-4-17-i
656
S-4-17-ii

ASPIRASI RINGAN
ASPIRASI SEDANG
ASPIRASI BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT

PASIEN RINGAN
PASIEN SEDANG
PASIEN BERAT

- 334 No
Kode
INA-CBG
657
S-4-17-iii
658
T-1-10-i
659
T-1-10-ii
660
T-1-10-iii
661
T-4-10-i
662
T-4-10-ii
663
T-4-10-iii
664
T-4-11-i
665
T-4-11-ii
666
T-4-11-iii
667
T-4-12-i
668
T-4-12-ii
669
T-4-12-iii
670
U-1-10-i
671
U-1-10-ii
672
U-1-10-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.933.102
4.051.095
4.129.757
4.208.419
1.858.625
1.914.384
1.951.556
1.988.729
2.496.007
2.570.888
2.620.808
2.670.728
4.541.051
4.677.282
4.768.103
4.858.924
813.016
837.406
853.666
869.927
1.549.427
1.595.910
1.626.899
1.657.887
2.252.447
2.320.020
2.365.069
2.410.118
804.026
828.147
844.227
860.308
1.265.308
1.303.267
1.328.573
1.353.879
2.038.038
2.099.179
2.139.940
2.180.701
1.688.340
1.738.990
1.772.757
1.806.524
2.551.833
2.628.388
2.679.424
2.730.461
3.969.735
4.088.827
4.168.221
4.247.616
1.797.083
1.850.996
1.886.937
1.922.879
3.667.058
3.777.070
3.850.411
3.923.752
15.835.098
16.310.151
16.626.853
16.943.555

DOKTER RINGAN
DOKTER SEDANG
DOKTER BERAT

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
7.797.740
8.031.673
8.187.627
8.343.582
10.396.987
10.708.897
10.916.837
11.124.776
17.467.864
17.991.900
18.341.257
18.690.615
673
U-1-11-i
674
U-1-11-ii
675
U-1-11-iii
676
U-1-12-i
4.765.283
4.908.242
5.003.548
5.098.853
677
U-1-12-ii
11.696.611
12.047.509
12.281.441
12.515.373
678
U-1-12-iii
15.188.270
15.643.919
15.947.684
16.251.449
679
U-1-13-i
5.198.494
5.354.448
5.458.418
5.562.388
680
U-1-13-ii
5.865.311
6.041.271
6.158.577
6.275.883
681
U-1-13-iii
11.309.974
11.649.274
11.875.473
12.101.673
2.868.365
2.954.416
3.011.784
3.069.151
3.520.061
3.625.663
3.696.064
3.766.465
4.171.371
4.296.513
4.379.940
4.463.367

682
U-1-14-i
683
U-1-14-ii
684
U-1-14-iii
685
U-1-15-i
1.684.700
1.735.241
1.768.935
1.802.629
686
U-1-15-ii
2.393.842
2.465.657
2.513.534
2.561.410
687
U-1-15-iii
4.717.161
4.858.676
4.953.019
5.047.362
- 335 No
Kode
INA-CBG
688
U-1-20-i
689
U-1-20-ii
690
U-1-20-iii
691
U-1-30-i
692
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.357.586
4.488.314
4.575.465
4.662.617
7.756.503
7.989.198
8.144.328
8.299.458
19.135.576
19.709.643
20.092.355
20.475.066
3.738.049
3.850.190
3.924.951
3.999.712
U-1-30-ii
5.046.366
5.197.757
5.298.684
5.399.612
693
U-1-30-iii
9.892.328
10.189.098
10.386.945
10.584.791
694
U-4-10-i
3.479.499
3.583.884
3.653.474
3.723.064
695
U-4-10-ii
8.722.374
8.984.045
9.158.492
9.332.940
696
U-4-10-iii
12.724.044
13.105.765
13.360.246
13.614.727
697
U-4-11-i
1.929.531
1.987.417
2.026.008
2.064.598
698
U-4-11-ii
2.894.297
2.981.126
3.039.012
3.096.897
699
U-4-11-iii
4.002.801
4.122.885
4.202.941
4.282.997
700
U-4-12-i
1.929.531
1.987.417
2.026.008
2.064.598
701
U-4-12-ii
2.249.389
2.316.871
2.361.858
2.406.846
702
U-4-12-iii
3.576.426
3.683.719
3.755.247
3.826.776
703
U-4-13-i
1.895.622
1.952.491
1.990.403
2.028.316
704
U-4-13-ii
2.203.772
2.269.885
2.313.960
2.358.036
705
U-4-13-iii
2.502.221
2.577.288
2.627.332
2.677.377
706
U-4-14-i
2.411.914
2.484.271
2.532.510
2.580.748
707
U-4-14-ii
2.894.297
2.981.126
3.039.012
3.096.897
708
U-4-14-iii
4.848.449
4.993.903
5.090.872
5.187.841
709
U-4-15-i
1.929.531
1.987.417
2.026.008
2.064.598
710
U-4-15-ii
2.411.914
2.484.271
2.532.510
2.580.748
711
U-4-15-iii
3.377.334
3.478.654
3.546.201
3.613.747
712
V-1-10-i
5.640.659
5.809.879
5.922.692
6.035.505
713
V-1-10-ii
6.498.117
6.693.061
6.823.023
6.952.985
714
V-1-10-iii
12.346.422
12.716.815
12.963.744
13.210.672
715
V-1-11-i
6.498.117
6.693.061
6.823.023
6.952.985
716
V-1-11-ii
7.252.008
7.469.568
7.614.608
7.759.648
717
V-1-11-iii
10.739.113
11.061.286
11.276.069
11.490.851
3.509.506
3.614.791
3.684.981
3.755.171
13.412.165
13.814.530
14.082.773
14.351.016
15.659.924
16.129.722
16.442.921
16.756.119
718
V-1-12-i
719
V-1-12-ii
720
V-1-12-iii


DAN TELINGA RINGAN
DAN TELINGA SEDANG
DAN TELINGA BERAT


KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

- 336 No
Kode
INA-CBG
721
V-1-13-i
722
V-1-13-ii
723
V-1-13-iii
724
V-1-14-i
725
V-1-14-ii
726
V-1-14-iii
727
V-1-15-i
728
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.319.273
5.478.851
5.585.237
5.691.622
10.108.145
10.411.390
10.613.553
10.815.716
15.595.481
16.063.345
16.375.255
16.687.165
6.412.446
6.604.819
6.733.068
6.861.317
9.326.353
9.606.143
9.792.670
9.979.197
12.677.820
13.058.154
13.311.711
13.565.267
3.023.111
3.113.804
3.174.267
3.234.729
V-1-15-ii
5.758.438
5.931.191
6.046.360
6.161.529
729
V-1-15-iii
10.123.224
10.426.921
10.629.385
10.831.850
730
V-4-10-i
4.867.972
5.014.011
5.111.371
5.208.730
731
V-4-10-ii
6.287.567
6.476.194
6.601.946
6.727.697
732
V-4-10-iii
12.016.645
12.377.144
12.617.477
12.857.810
733
V-4-11-i
2.475.546
2.549.812
2.599.323
2.648.834
734
V-4-11-ii
3.617.168
3.725.683
3.798.027
3.870.370
735
V-4-11-iii
5.968.088
6.147.131
6.266.493
6.385.854
736
W-1-01-i
7.279.318
7.497.697
7.643.284
7.788.870
737
W-1-01-ii
8.767.593
9.030.621
9.205.973
9.381.324
738
W-1-01-iii
19.365.871
19.946.847
20.334.165
20.721.482
739
W-1-10-i
2.027.281
2.088.100
2.128.645
2.169.191
740
W-1-10-ii
3.783.239
3.896.737
3.972.401
4.048.066
741
W-1-10-iii
6.188.179
6.373.825
6.497.588
6.621.352
742
W-1-11-i
2.105.671
2.168.841
2.210.955
2.253.068
743
W-1-11-ii
4.061.053
4.182.885
4.264.106
4.345.327
744
W-1-11-iii
7.797.740
8.031.673
8.187.627
8.343.582
745
W-1-12-i
1.913.319
1.970.718
2.008.985
2.047.251
746
W-1-12-ii
2.175.407
2.240.669
2.284.177
2.327.685
747
W-1-12-iii
3.341.699
3.441.950
3.508.784
3.575.618
748
W-1-13-i
2.277.301
2.345.620
2.391.166
2.436.712
749
W-1-13-ii
2.472.493
2.546.668
2.596.118
2.645.567
750
W-1-13-iii
3.321.014
3.420.645
3.487.065
3.553.485
751
W-1-20-i
6.204.997
6.391.147
6.515.247
6.639.347
752
W-1-20-ii
8.728.260
8.990.108
9.164.673
9.339.238

NON KOMPLEK (BERAT)

RINGAN
SEDANG
BERAT

SERVIK RINGAN
SERVIK SEDANG
SERVIK BERAT
ENDOSKOP RINGAN
ENDOSKOP SEDANG
ENDOSKOP BERAT
- 337 No
Kode
INA-CBG
753
W-1-20-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
11.026.252
11.357.040
11.577.565
11.798.090
3.387.306
3.488.926
3.556.672
3.624.418
5.402.929
5.565.017
5.673.075
5.781.134
14.367.717
14.798.749
15.086.103
15.373.457
754
W-1-30-i
755
W-1-30-ii
756
W-1-30-iii
757
W-4-10-i
2.526.082
2.601.864
2.652.386
2.702.908
758
W-4-10-ii
3.414.283
3.516.711
3.584.997
3.653.282
759
W-4-10-iii
7.718.125
7.949.668
8.104.031
8.258.393
760
W-4-11-i
2.411.914
2.484.271
2.532.510
2.580.748
761
W-4-11-ii
3.859.062
3.974.834
4.052.015
4.129.197
762
W-4-11-iii
4.689.904
4.830.602
4.924.400
5.018.198
1.929.531
1.987.417
2.026.008
2.064.598
2.653.105
2.732.698
2.785.761
2.838.823
2.957.918
3.046.655
3.105.814
3.164.972

763
W-4-12-i
764
W-4-12-ii
765
W-4-12-iii
766
W-4-13-i
ABORTUS RINGAN
1.058.178
1.089.923
1.111.087
1.132.250
767
W-4-13-ii
ABORTUS SEDANG
1.447.148
1.490.563
1.519.506
1.548.449
768
W-4-13-iii
ABORTUS BERAT
1.929.531
1.987.417
2.026.008
2.064.598
769
W-4-14-i
1.447.148
1.490.563
1.519.506
1.548.449
770
W-4-14-ii
1.861.266
1.917.104
1.954.330
1.991.555
771
W-4-14-iii
2.342.043
2.412.304
2.459.145
2.505.986
772
W-4-15-i
1.206.753
1.242.956
1.267.091
1.291.226
773
W-4-15-ii
1.342.140
1.382.404
1.409.247
1.436.089
774
W-4-15-iii
1.858.320
1.914.069
1.951.236
1.988.402
775
W-4-16-i
1.447.148
1.490.563
1.519.506
1.548.449
776
W-4-16-ii
1.929.531
1.987.417
2.026.008
2.064.598
777
W-4-16-iii
2.630.653
2.709.573
2.762.186
2.814.799
778
W-4-17-i
1.181.967
1.217.426
1.241.065
1.264.704
779
W-4-17-ii
1.929.531
1.987.417
2.026.008
2.064.598
780
W-4-17-iii
3.650.289
3.759.798
3.832.804
3.905.809
781
Z-4-10-i
REHABILITASI RINGAN
3.310.847
3.410.172
3.476.389
3.542.606
782
Z-4-10-ii
REHABILITASI SEDANG
4.394.671
4.526.512
4.614.405
4.702.298
783
Z-4-10-iii
REHABILITASI BERAT
6.243.050
6.430.341
6.555.202
6.680.063
784
Z-4-11-i
2.890.005
2.976.705
3.034.505
3.092.305
785
Z-4-11-ii
3.478.927
3.583.295
3.652.874
3.722.452
786
Z-4-11-iii
5.504.281
5.669.410
5.779.496
5.889.581
- 338 No
Kode
INA-CBG
787
Z-4-12-i
788
Z-4-12-ii
789
Z-4-12-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.777.467
1.830.791
1.866.341
1.901.890
3.621.531
3.730.177
3.802.608
3.875.038
4.602.393
4.740.465
4.832.513
4.924.560
- 339 b. RawatJalan
No
Kode
INA-CBG
B-2-10-0
B-2-11-0
Deskripsi (INA-CBG)
LAPAROSKOPI
PANKREAS
LAPAROSKOPI
EMPEDU
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
800.166
824.171
840.174
856.178
1.037.940
1.069.079
1.089.837
1.110.596
1.930.187
1.988.093
2.026.696
2.065.300
1.595.112
1.642.966
1.674.868
1.706.770
1.332.579
1.372.556
1.399.208
1.425.859
467.208
481.224
490.568
499.913
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
1.041.813
1.073.067
1.093.903
1.114.739
B-3-12-0

214.058
220.480
224.761
229.042
C-3-10-0
583.921
601.438
613.117
624.795
10
C-3-11-0

KANDUNG KEMIH
923.492
951.197
969.667
988.137
11
C-3-12-0
209.354
215.634
219.822
224.009
12
C-3-13-0
203.297
209.396
213.462
217.528
13
C-3-14-0
1.730.670
1.782.590
1.817.203
1.851.817
14
C-3-15-0
1.586.228
1.633.815
1.665.539
1.697.264
15
C-3-16-0
359.718
370.510
377.704
384.899
16
C-3-17-0

LEHER
238.627
245.785
250.558
255.330
17
C-3-18-0
105.797
108.971
111.087
113.202
18
C-3-19-0

MYELOMA ATAU TESTIS
149.618
154.107
157.099
160.091
19
C-3-20-0
2.979.648
3.069.038
3.128.631
3.188.224
20
C-3-21-0
170.741
175.863
179.278
182.693
21
C-3-22-0
749.644
772.133
787.126
802.119
22
C-3-23-0
121.426
125.069
127.497
129.926
23
D-2-10-0

TULANG
1.028.737
1.059.599
1.080.174
1.100.749
24
D-2-11-0
PROSEDUR LIMPA
1.288.155
1.326.799
1.352.563
1.378.326
1.080.397
1.112.809
1.134.417
1.156.025
237.115
244.228
248.970
253.713
171.748
176.900
180.335
183.770
445.907
459.284
468.203
477.121
264.509
272.444
277.734
283.024
191.760
197.513
201.348
205.183
191.760
197.513
201.348
205.183
25
D-2-21-0
26
D-2-22-0
27
D-3-10-0
28
D-3-11-0
29
E-2-10-0
30
E-2-21-0
31
E-2-22-0

OVARIUM
GASTROINTESTINAL
GINJAL ATAU PROSTAT

TYMUS
TYMUS
TULANG
PEMBENTUK DARAH
PARATIROID
THYROGLOSSAL
- 340 No
Kode
INA-CBG
32
E-3-10-0
33
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

ENDOKRIN
223.004
229.694
234.155
238.615
F-3-10-0
TERAPI SHOCK
311.084
320.416
326.638
332.860
34
F-5-10-0
381.178
392.614
400.237
407.861
35
F-5-11-0
TERAPI KELOMPOK
251.352
258.893
263.920
268.947
36
F-5-12-0
321.648
331.297
337.730
344.163
37
F-5-13-0
272.414
280.587
286.035
291.483
38
F-5-14-0
182.753
188.236
191.891
195.546
39
F-5-15-0
171.446
176.590
180.019
183.447
40
F-5-16-0
178.578
183.935
187.507
191.078
41
G-2-10-0
150.376
154.887
157.895
160.903
42
G-2-11-0
1.303.524
1.342.630
1.368.700
1.394.771
43
G-2-12-0

EKSTRAKRANIAL
1.889.128
1.945.801
1.983.584
2.021.366
44
G-2-13-0
463.445
477.348
486.617
495.886
45
G-2-21-0
845.246
870.603
887.508
904.413
46
G-2-22-0
767.132
790.146
805.489
820.832
47
G-2-31-0
1.265.835
1.303.810
1.329.127
1.354.444
48
G-2-32-0
648.866
668.332
681.309
694.287
49
G-3-10-0
257.539
265.265
270.416
275.567
50
G-3-11-0
342.993
353.282
360.142
367.002
51
G-3-12-0
561.999
578.859
590.099
601.339
52
G-3-13-0
562.063
578.925
590.167
601.408
53
H-2-21-0
1.359.177
1.399.952
1.427.136
1.454.320
54
H-2-22-0
353.344
363.945
371.012
378.078
55
H-2-23-0
353.344
363.945
371.012
378.078
56
H-2-31-0
2.251.364
2.318.905
2.363.932
2.408.959
57
H-2-32-0
234.314
241.344
246.030
250.716
58
H-2-33-0
353.344
363.945
371.012
378.078
59
H-2-34-0
1.010.017
1.040.317
1.060.517
1.080.718
60
H-2-35-0
332.823
342.808
349.465
356.121
61
H-2-36-0
1.796.503
1.850.398
1.886.328
1.922.258
62
H-2-37-0

1.912.456
1.969.830
2.008.079
2.046.328
63
H-3-10-0
665.395
685.357
698.665
711.973
64
H-3-11-0
349.924
360.422
367.420
374.419

AKUT
MENTAL
PROSEDUR KRANIOTOMI

MATA
MATA
MATA
MATA
MATA
- 341 No
Kode
INA-CBG
65
H-3-12-0
66
H-3-13-0
67
I-2-11-0
68
I-2-12-0
69
I-2-13-0
70
I-2-14-0
71
I-2-15-0
Deskripsi (INA-CBG)
MATA
TORASIK
ABDOMEN
PENGGANTIAN ALAT
DARAH VENA
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
365.339
376.299
383.605
390.912
354.722
365.364
372.458
379.552
2.220.020
2.286.620
2.331.021
2.375.421
1.560.916
1.607.744
1.638.962
1.670.180
1.983.831
2.043.345
2.083.022
2.122.699
3.510.958
3.616.286
3.686.505
3.756.725
211.142
217.476
221.699
225.922
2.217.614
2.284.142
2.328.495
2.372.847
731.084
753.016
767.638
782.259
72
I-2-16-0
73
I-2-17-0
74
I-2-21-0
1.711.683
1.763.033
1.797.267
1.831.500
75
I-2-22-0
1.611.849
1.660.204
1.692.441
1.724.678
76
I-2-23-0
329.860
339.756
346.353
352.950
77
I-2-31-0
2.565.433
2.642.396
2.693.705
2.745.014
78
I-2-32-0
3.354.681
3.455.321
3.522.415
3.589.508
79
I-2-41-0
2.249.355
2.316.835
2.361.822
2.406.809
80
I-2-42-0

LAIN
2.615.247
2.693.704
2.746.009
2.798.314
81
I-3-10-0
PROSEDUR RESUSITASI
331.982
341.942
348.581
355.221
82
I-3-11-0
175.220
180.476
183.981
187.485
83
I-3-12-0
1.018.310
1.048.859
1.069.225
1.089.591
84
I-3-13-0
334.452
344.486
351.175
357.864
85
I-3-14-0
214.373
220.804
225.091
229.379
189.904
195.601
199.399
203.197
1.175.761
1.211.034
1.234.549
1.258.065
189.532
195.218
199.009
202.800
955.125
983.779
1.002.882
1.021.984
1.238.883
1.276.050
1.300.827
1.325.605

PACU JANTUNG

KARDIOVASKULAR
PERNAFASAN
PENDEK
86
I-3-15-0
87
J-2-10-0
88
J-2-21-0
89
J-2-22-0
90
J-2-31-0
91
J-2-32-0
921.935
949.593
968.031
986.470
92
J-3-10-0
191.760
197.513
201.348
205.183
93
J-3-11-0

PADA DADA
541.879
558.136
568.973
579.811
94
J-3-12-0
209.354
215.634
219.822
224.009
95
J-3-13-0
308.117
317.360
323.522
329.685
96
J-3-14-0
327.099
336.912
343.454
349.996
- 342 No
Kode
INA-CBG
97
J-3-15-0
98
J-3-16-0
99
J-3-17-0
100
K-2-10-0
101
K-2-11-0
102
K-2-12-0

103
K-2-13-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
286.840
295.445
301.182
306.919
327.099
336.912
343.454
349.996
191.760
197.513
201.348
205.183
551.950
568.509
579.548
590.587
1.178.639
1.213.999
1.237.571
1.261.144
904.758
931.900
949.996
968.091
1.472.542
1.516.718
1.546.169
1.575.620
191.760
197.513
201.348
205.183
191.760
197.513
201.348
205.183
2.464.571
2.538.508
2.587.799
2.637.091
828.710
853.571
870.145
886.719
191.760
197.513
201.348
205.183

PERNAFASAN
KECIL

FEMORALIS
USUS BESAR
ATAS
ATAS
104
K-2-14-0
105
K-2-21-0
106
K-2-22-0
107
K-2-31-0
108
K-2-32-0
109
K-2-41-0
912.841
940.226
958.483
976.740
110
K-2-42-0

260.810
268.634
273.850
279.067
111
K-2-51-0
604.904
623.051
635.149
647.247
112
K-2-52-0
329.860
339.756
346.353
352.950
113
K-2-53-0
191.760
197.513
201.348
205.183
114
K-3-10-0

GASTROINTESTINAL
364.906
375.853
383.151
390.450
115
K-3-11-0
219.380
225.961
230.349
234.736
116
K-3-12-0
222.479
229.153
233.603
238.052
117
K-3-13-0
191.760
197.513
201.348
205.183
513.921
529.338
539.617
549.895
248.179
255.625
260.588
265.552
328.854
338.719
345.296
351.873
1.130.610
1.164.529
1.187.141
1.209.753
724.713
746.455
760.949
775.443
327.099
336.912
343.454
349.996
329.860
339.756
346.353
352.950

GASTROINTESTINAL
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
118
K-3-14-0
119
K-3-15-0
120
K-3-16-0
121
L-2-21-0
122
L-2-22-0
123
L-2-31-0
124
L-2-32-0
125
L-2-41-0
987.727
1.017.359
1.037.113
1.056.868
126
L-2-42-0

221.531
228.177
232.608
237.038
127
L-2-51-0
1.478.782
1.523.145
1.552.721
1.582.297
L-2-52-0

1.131.317
1.165.256
1.187.883
1.210.509
128
- 343 No
Kode
INA-CBG
129
L-2-53-0
130
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

191.760
197.513
201.348
205.183
L-3-10-0
260.810
268.634
273.850
279.067
131
L-3-11-0
253.264
260.862
265.928
270.993
132
L-3-12-0
192.885
198.672
202.529
206.387
133
M-2-10-0
1.512.902
1.558.289
1.588.547
1.618.805
134
M-2-21-0
1.354.908
1.395.555
1.422.653
1.449.752
135
M-2-22-0
329.860
339.756
346.353
352.950
136
M-2-31-0
PROSEDUR BUNION
822.971
847.660
864.119
880.578
137
M-2-32-0
260.810
268.634
273.850
279.067
138
M-2-41-0

TULANG
260.810
268.634
273.850
279.067
139
M-2-42-0
89.882
92.579
94.376
96.174
140
M-2-51-0
191.760
197.513
201.348
205.183
141
M-2-52-0
191.760
197.513
201.348
205.183
142
M-2-61-0
PROSEDUR ARTROSKOPI
939.915
968.113
986.911
1.005.709
143
M-2-62-0
191.760
197.513
201.348
205.183
945.000
973.350
992.250
1.011.150
1.288.785
1.327.448
1.353.224
1.379.000
191.760
197.513
201.348
205.183
951.462
980.006
999.035
1.018.064
918.201
945.747
964.111
982.475

DAN WAJAH
PAHA
PAHA

TULANG
WAJAH
WAJAH
BAWAH
BAWAH
144
M-2-63-0
145
M-2-64-0
146
M-2-65-0
147
M-2-71-0
148
M-2-72-0
149
M-2-81-0
1.369.234
1.410.311
1.437.695
1.465.080
150
M-2-82-0
994.660
1.024.500
1.044.393
1.064.287
151
M-2-83-0
191.760
197.513
201.348
205.183
152
M-2-84-0
191.760
197.513
201.348
205.183
153
M-3-10-0
547.320
563.739
574.686
585.632
154
M-3-11-0
303.455
312.559
318.628
324.697
155
M-3-12-0
686.241
706.828
720.553
734.278
156
M-3-13-0
223.733
230.445
234.920
239.394
157
M-3-14-0

TERTUTUP
382.398
393.870
401.517
409.165
158
M-3-15-0
168.470
173.524
176.893
180.262
159
M-3-16-0

191.760
197.513
201.348
205.183
160
M-3-17-0
209.354
215.634
219.822
224.009
161
N-2-11-0
2.533.336
2.609.336
2.660.002
2.710.669

PERGELANGAN TANGAN
PERGELANGAN TANGAN
MUSKULOSKELETAL
SKELETAL
- 344 No
Kode
INA-CBG
162
N-2-12-0
163
N-2-21-0
164
N-2-22-0
165
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.465.510
1.509.475
1.538.785
1.568.095
1.457.785
1.501.518
1.530.674
1.559.830
329.860
339.756
346.353
352.950
N-2-23-0
329.860
339.756
346.353
352.950
166
N-2-24-0
1.065.997
1.097.977
1.119.297
1.140.617
167
N-2-31-0
897.397
924.319
942.267
960.214
168
N-2-32-0
329.860
339.756
346.353
352.950
169
N-2-41-0
329.860
339.756
346.353
352.950
170
N-2-42-0
557.857
574.592
585.749
596.907
171
N-3-10-0
329.860
339.756
346.353
352.950
172
N-3-11-0
382.190
393.656
401.300
408.943
173
N-3-12-0
295.335
304.195
310.102
316.008
174
N-3-13-0
329.860
339.756
346.353
352.950
175
N-3-14-0
283.827
292.341
298.018
303.695
176
N-3-15-0
727.803
749.637
764.193
778.749
177
O-7-10-0
121.512
125.157
127.587
130.018
178
O-7-11-0
669.197
689.273
702.657
716.041
179
O-7-12-0
243.677
250.988
255.861
260.735
180
O-7-13-0
135.425
139.488
142.196
144.905
181
P-9-10-0
180.623
186.042
189.654
193.267
182
P-9-11-0
180.623
186.042
189.654
193.267
183
P-9-12-0
180.623
186.042
189.654
193.267
184
P-9-13-0
180.623
186.042
189.654
193.267
185
P-9-14-0
180.623
186.042
189.654
193.267
186
P-9-15-0
115.133
118.587
120.890
123.192
187
P-9-16-0
180.623
186.042
189.654
193.267
188
P-9-17-0
179.846
185.242
188.839
192.436
189
Q-5-10-0
235.410
242.472
247.180
251.888
190
Q-5-11-0
176.433
181.726
185.255
188.783
191
Q-5-12-0
GIGI
155.503
160.169
163.279
166.389
192
Q-5-13-0
MEDICAL CHECK-UP
118.176
121.721
124.085
126.448
193
Q-5-14-0
130.032
133.933
136.534
139.134


DAN URETHRA
URETHRA
TRANSURETHRA
TRANSURETHRA
SALURAN KEMIH
KEMIH
KEMIH
PROSEDUR DIALISIS
CAESAR
VAGINAL/JALAN LAHIR

ASPIRASI
- 345 No
Kode
INA-CBG
194
Q-5-15-0
195
Q-5-16-0
VAKSINASI
196
Q-5-17-0
PASANG INFUS
197
Q-5-18-0
198
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
89.423
92.106
93.894
95.683
101.069
104.101
106.122
108.143
87.422
90.044
91.793
93.541
164.555
169.492
172.783
176.074
Q-5-19-0
183.963
189.481
193.161
196.840
199
Q-5-20-0
ABORSI MENGANCAM
123.304
127.003
129.469
131.935
200
Q-5-21-0
ABORSI
121.625
125.273
127.706
130.138
201
Q-5-22-0
130.032
133.933
136.534
139.134
202
Q-5-23-0
159.194
163.969
167.153
170.337
203
Q-5-24-0
108.727
111.989
114.163
116.338
204
Q-5-25-0
169.557
174.644
178.035
181.426
205
Q-5-26-0
BRONKIAL AKUT
239.997
247.197
251.997
256.797
206
Q-5-27-0
170.793
175.917
179.333
182.749
207
Q-5-28-0
138.594
142.752
145.524
148.296
208
Q-5-29-0

JANTUNG LAIN-LAIN
392.384
404.155
412.003
419.850
209
Q-5-30-0
454.730
468.372
477.467
486.561
210
Q-5-31-0
FRAKTUR
162.230
167.096
170.341
173.586
211
Q-5-32-0
SALURAN KEMIH AKUT
187.898
193.535
197.293
201.051
212
Q-5-33-0
HEMATOLOGI AKUT
196.729
202.631
206.565
210.500
213
Q-5-34-0
INFEKSI VIRUS HIV
279.467
287.851
293.441
299.030
214
Q-5-35-0
INFEKSI AKUT
316.908
326.416
332.754
339.092
215
Q-5-36-0
369.060
380.132
387.513
394.894
216
Q-5-37-0

SHOCK
188.240
193.887
197.652
201.416
217
Q-5-38-0
PARU AKUT
251.024
258.554
263.575
268.595
218
Q-5-39-0
160.637
165.456
168.668
171.881
219
Q-5-40-0
157.610
162.339
165.491
168.643
220
Q-5-41-0
218.189
224.735
229.098
233.462
221
Q-5-42-0
171.069
176.201
179.622
183.044
222
Q-5-43-0
246.349
253.739
258.666
263.593
223
Q-5-44-0
201.055
207.087
211.108
215.129
224
T-2-10-0

TERAPI DETOKSIKASI
104.284
107.412
109.498
111.584
225
U-2-10-0
1.391.785
1.433.539
1.461.375
1.489.210
226
U-2-11-0

LEHER
1.654.292
1.703.920
1.737.006
1.770.092
227
U-2-12-0
182.015
187.476
191.116
194.756
- 346 No
Kode
INA-CBG
228
U-2-13-0
229
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
238.627
245.785
250.558
255.330
U-2-14-0
443.260
456.558
465.423
474.288
230
U-2-15-0
251.851
259.406
264.443
269.480
231
U-2-21-0
293.367
302.168
308.035
313.902
232
U-2-22-0
566.808
583.812
595.148
606.484
233
U-2-23-0
742.701
764.982
779.836
794.690
234
U-2-24-0
625.936
644.714
657.233
669.751
235
U-2-25-0
238.627
245.785
250.558
255.330
236
U-2-31-0
191.760
197.513
201.348
205.183
237
U-2-32-0
238.627
245.785
250.558
255.330
238
U-3-10-0
228.140
234.984
239.546
244.109
239
U-3-11-0
242.213
249.479
254.324
259.168
240
U-3-12-0
107.106
110.319
112.462
114.604
241
U-3-13-0
235.428
242.491
247.199
251.908
242
U-3-14-0
216.310
222.799
227.125
231.451
243
U-3-15-0
188.641
194.301
198.073
201.846
244
U-3-16-0
PROSEDUR PADA GIGI
212.753
219.136
223.391
227.646
245
V-2-10-0

PROSTAT
2.075.654
2.137.923
2.179.436
2.220.949
246
V-2-11-0
234.081
241.103
245.785
250.467
746.986
769.395
784.335
799.275
329.860
339.756
346.353
352.950
329.860
339.756
346.353
352.950

(RHINOPLASTY)

RONGGA HIDUNG
TENGGOROKAN
PROSEDUR PADA PENIS

SKROTUM
SKROTUM
TRANSURETHRAL
247
V-2-12-0
248
V-2-13-0
249
V-2-14-0
250
V-2-15-0
SIRKUMSISI/SUNAT
180.623
186.042
189.654
193.267
251
V-3-10-0
376.702
388.003
395.537
403.071
252
V-3-11-0
796.919
820.827
836.765
852.704
253
V-3-12-0
460.083
473.885
483.087
492.288
254
W-2-10-0
168.470
173.524
176.893
180.262
255
W-2-11-0
430.545
443.462
452.073
460.684
256
W-2-12-0
796.919
820.827
836.765
852.704
257
W-2-13-0
127.812
131.646
134.202
136.758
258
W-2-21-0
1.602.020
1.650.081
1.682.121
1.714.162
259
W-2-22-0
168.470
173.524
176.893
180.262

PROSEDUR ABORSI
RAHIM & LEHER RAHIM
TERHALANG/TERGANGGU
TERHALANG/TERGANGGU
PANGGUL TERBUKA
PANGGUL TERBUKA
- 347 No
Kode
INA-CBG
260
W-2-23-0
Deskripsi (INA-CBG)
JALAN LAHIR
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
562.191
579.057
590.301
601.545
1.845.502
1.900.867
1.937.777
1.974.688
1.294.335
1.333.165
1.359.051
1.384.938
261
W-2-31-0
262
W-2-32-0
263
W-2-33-0
550.109
566.613
577.615
588.617
264
W-2-34-0
187.102
192.715
196.457
200.199
265
W-3-10-0
454.730
468.372
477.466
486.561
266
W-3-11-0
363.498
374.403
381.673
388.943
267
W-3-12-0
168.470
173.524
176.893
180.262
268
Z-3-10-0
1.907.300
1.964.519
2.002.665
2.040.811
269
Z-3-11-0

EMPEDU
1.457.785
1.501.518
1.530.674
1.559.830
270
Z-3-12-0
243.415
250.717
255.586
260.454
271
Z-3-13-0

LAIN-LAIN
1.485.384
1.529.945
1.559.653
1.589.361
272
Z-3-14-0
DIAGNOSTIK TIDUR
293.706
302.518
308.392
314.266
273
Z-3-15-0
191.760
197.513
201.348
205.183
274
Z-3-16-0

(MRI)
615.491
633.956
646.265
658.575
275
Z-3-17-0
PENGOBATAN NUKLIR
258.396
266.148
271.316
276.484
276
Z-3-18-0
CT-SCAN KEPALA
248.960
256.429
261.408
266.387
277
Z-3-19-0
CT SCAN LAIN-LAIN
259.119
266.892
272.075
277.257
278
Z-3-20-0
176.233
181.520
185.045
188.569
279
Z-3-21-0
168.470
173.524
176.893
180.262
280
Z-3-22-0
189.934
195.632
199.431
203.230
281
Z-3-23-0
197.833
203.768
207.725
211.681
282
Z-3-24-0
388.703
400.364
408.138
415.912
283
Z-3-25-0
173.128
178.321
181.784
185.247
284
Z-3-26-0
195.668
201.538
205.452
209.365
285
Z-3-27-0
PERAWATAN LUKA
186.810
192.415
196.151
199.887
286
Z-3-28-0
IMAGING PAYUDARA
191.760
197.513
201.348
205.183
287
Z-3-29-0
IMAGING LAIN-LAIN
552.686
569.267
580.321
591.375
288
Z-3-30-0
FOTOTERAPI
93.273
96.071
97.937
99.802
- 348 4. RUMAH SAKIT ORTOPEDIKELAS B PENDIDIKAN

a. RawatInap
No
Kode
INA-CBG
A-4-10-i
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
SEPTIKEMIA RINGAN
2.007.491
2.067.716
2.107.866
2.148.016
A-4-10-ii
SEPTIKEMIA SEDANG
3.430.982
3.533.912
3.602.532
3.671.151
A-4-10-iii
SEPTIKEMIA BERAT
4.911.856
5.059.212
5.157.449
5.255.686
A-4-11-i
5.386.659
5.548.258
5.655.991
5.763.725
A-4-11-ii
8.321.765
8.571.418
8.737.853
8.904.289
A-4-11-iii
9.328.006
9.607.846
9.794.406
9.980.966
A-4-12-i
DEMAM RINGAN
1.929.531
1.987.417
2.026.008
2.064.598
A-4-12-ii
DEMAM SEDANG
3.030.773
3.121.697
3.182.312
3.242.928
A-4-12-iii
DEMAM BERAT
3.468.498
3.572.553
3.641.923
3.711.293
10
A-4-13-i
2.411.914
2.484.271
2.532.510
2.580.748
11
A-4-13-ii
2.894.297
2.981.126
3.039.012
3.096.897
12
A-4-13-iii
3.517.676
3.623.206
3.693.559
3.763.913
13
A-4-14-i
1.929.531
1.987.417
2.026.008
2.064.598
14
A-4-14-ii
3.014.513
3.104.949
3.165.239
3.225.529
15
A-4-14-iii
3.364.109
3.465.032
3.532.314
3.599.597
16
A-4-15-i
INFEKSI HIV RINGAN
2.894.297
2.981.126
3.039.012
3.096.897
17
A-4-15-ii
INFEKSI HIV SEDANG
4.341.445
4.471.688
4.558.517
4.645.346
18
A-4-15-iii
INFEKSI HIV BERAT
6.612.330
6.810.700
6.942.947
7.075.193
19
B-1-01-i
32.087.791
33.050.425
33.692.181
34.333.937
20
B-1-01-ii
35.401.413
36.463.455
37.171.483
37.879.512
21
B-1-01-iii
62.101.363
63.964.404
65.206.431
66.448.458
22
B-1-10-i
4.160.073
4.284.875
4.368.077
4.451.278
23
B-1-10-ii
10.601.870
10.919.927
11.131.964
11.344.001
24
B-1-10-iii
20.209.204
20.815.481
21.219.665
21.623.849
25
B-1-11-i
3.114.506
3.207.941
3.270.231
3.332.521
26
B-1-11-ii
7.817.704
8.052.235
8.208.589
8.364.943
27
B-1-11-iii
9.801.460
10.095.504
10.291.533
10.487.563
28
B-1-12-i
6.643.353
6.842.654
6.975.521
7.108.388
29
B-1-12-ii
14.238.332
14.665.481
14.950.248
15.235.015
30
B-1-12-iii
17.328.586
17.848.444
18.195.015
18.541.587

RINGAN
SEDANG

LAIN-LAIN RINGAN
LAIN-LAIN SEDANG
LAIN-LAIN BERAT

(RINGAN)
(SEDANG)
(BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT
- 349 No
Kode
INA-CBG
31
B-1-13-i
32
B-1-13-ii
33
B-1-13-iii
34
B-1-14-i
35
B-1-14-ii
36
B-1-14-iii
37
B-4-10-i
38
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.353.242
4.483.839
4.570.904
4.657.969
7.090.799
7.303.523
7.445.339
7.587.155
10.453.827
10.767.442
10.976.519
11.185.595
5.911.396
6.088.738
6.206.966
6.325.194
6.574.665
6.771.905
6.903.398
7.034.892
10.285.282
10.593.841
10.799.546
11.005.252
1.653.919
1.703.536
1.736.615
1.769.693
B-4-10-ii
2.411.914
2.484.271
2.532.510
2.580.748
39
B-4-10-iii
4.038.334
4.159.484
4.240.251
4.321.017
40
B-4-11-i
3.993.179
4.112.975
4.192.838
4.272.702
41
B-4-11-ii
6.070.630
6.252.749
6.374.161
6.495.574
42
B-4-11-iii
6.538.279
6.734.428
6.865.193
6.995.959
43
B-4-12-i
3.503.741
3.608.854
3.678.928
3.749.003
44
B-4-12-ii
4.967.443
5.116.466
5.215.815
5.315.164
45
B-4-12-iii
9.440.510
9.723.725
9.912.535
10.101.346
46
B-4-13-i
2.894.297
2.981.126
3.039.012
3.096.897
47
B-4-13-ii
3.430.547
3.533.463
3.602.074
3.670.685
48
B-4-13-iii
6.098.667
6.281.627
6.403.601
6.525.574
49
B-4-14-i
3.034.228
3.125.255
3.185.940
3.246.624
50
B-4-14-ii
3.409.636
3.511.925
3.580.118
3.648.311
51
B-4-14-iii
4.504.830
4.639.975
4.730.072
4.820.168
52
C-4-10-i
3.086.588
3.179.186
3.240.917
3.302.649
53
C-4-10-ii
5.996.917
6.176.824
6.296.763
6.416.701
54
C-4-10-iii
LEUKEMIA AKUT BERAT
9.165.273
9.440.231
9.623.537
9.806.842
55
C-4-11-i
3.105.097
3.198.250
3.260.352
3.322.454
56
C-4-11-ii
3.859.062
3.974.834
4.052.015
4.129.197
57
C-4-11-iii
7.185.008
7.400.559
7.544.259
7.687.959
58
C-4-12-i
RADIOTERAPI RINGAN
1.929.531
1.987.417
2.026.008
2.064.598
59
C-4-12-ii
RADIOTERAPI SEDANG
5.817.981
5.992.520
6.108.880
6.225.240
60
C-4-12-iii
RADIOTERAPI BERAT
11.811.667
12.166.017
12.402.250
12.638.484
61
C-4-13-i
KEMOTERAPI RINGAN
1.929.531
1.987.417
2.026.008
2.064.598
62
C-4-13-ii
KEMOTERAPI SEDANG
3.859.062
3.974.834
4.052.015
4.129.197
63
C-4-13-iii
KEMOTERAPI BERAT
5.049.298
5.200.776
5.301.762
5.402.748

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT

PANCREAS RINGAN
PANCREAS SEDANG
PANCREAS BERAT
(RINGAN)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT
- 350 No
Kode
INA-CBG
64
C-4-14-i
65
C-4-14-ii
66
C-4-14-iii
67
D-1-10-i
68
D-1-10-ii
69
D-1-10-iii
70
D-1-11-i
71
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.740.115
2.822.319
2.877.121
2.931.923
4.004.032
4.124.153
4.204.233
4.284.314
6.104.030
6.287.151
6.409.232
6.531.312
20.532.500
21.148.475
21.559.125
21.969.775
31.272.572
32.210.749
32.836.201
33.461.652
42.382.880
43.654.367
44.502.024
45.349.682
4.621.765
4.760.417
4.852.853
4.945.288
D-1-11-ii
12.054.410
12.416.042
12.657.130
12.898.219
72
D-1-11-iii
16.585.000
17.082.550
17.414.250
17.745.950
73
D-1-20-i
5.198.494
5.354.448
5.458.418
5.562.388
74
D-1-20-ii
11.696.611
12.047.509
12.281.441
12.515.373
75
D-1-20-iii
22.743.410
23.425.712
23.880.580
24.335.448
76
D-4-10-i
1.853.433
1.909.036
1.946.105
1.983.174
77
D-4-10-ii
3.742.430
3.854.703
3.929.552
4.004.400
78
D-4-10-iii
4.823.828
4.968.543
5.065.019
5.161.496
79
D-4-11-i
2.411.914
2.484.271
2.532.510
2.580.748
80
D-4-11-ii
4.446.914
4.580.322
4.669.260
4.758.198
81
D-4-11-iii
6.736.456
6.938.549
7.073.279
7.208.008
82
D-4-12-i
2.474.164
2.548.388
2.597.872
2.647.355
83
D-4-12-ii
3.431.908
3.534.865
3.603.503
3.672.142
84
D-4-12-iii
5.269.697
5.427.787
5.533.181
5.638.575
85
D-4-13-i
1.929.531
1.987.417
2.026.008
2.064.598
86
D-4-13-ii
2.894.297
2.981.126
3.039.012
3.096.897
87
D-4-13-iii
3.376.680
3.477.980
3.545.513
3.613.047
88
D-4-14-i
2.411.914
2.484.271
2.532.510
2.580.748
89
D-4-14-ii
5.427.955
5.590.794
5.699.353
5.807.912
90
D-4-14-iii
6.474.800
6.669.044
6.798.540
6.928.036
91
E-1-01-i
5.065.306
5.217.265
5.318.571
5.419.877
92
E-1-01-ii
6.635.068
6.834.120
6.966.822
7.099.523
93
E-1-01-iii
13.732.161
14.144.126
14.418.769
14.693.413
94
E-1-10-i
4.712.923
4.854.311
4.948.569
5.042.828
95
E-1-10-ii
5.720.382
5.891.994
6.006.401
6.120.809
96
E-1-10-iii
12.056.882
12.418.588
12.659.726
12.900.864

RINGAN
SEDANG
BERAT
TULANG RINGAN
TULANG SEDANG
TULANG BERAT


RINGAN
SEDANG
BERAT
- 351 No
Kode
INA-CBG
97
E-1-20-i
98
E-1-20-ii
99
E-1-20-iii
100
E-4-10-i
101
E-4-10-ii
102
E-4-10-iii
103
E-4-11-i
104
E-4-11-ii
105
E-4-11-iii
106
E-4-12-i
107
E-4-12-ii
108
E-4-12-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.976.863
6.156.169
6.275.707
6.395.244
8.005.043
8.245.194
8.405.295
8.565.396
17.736.913
18.269.020
18.623.758
18.978.497
2.452.474
2.526.049
2.575.098
2.624.148
3.756.577
3.869.275
3.944.406
4.019.538
6.556.854
6.753.560
6.884.697
7.015.834
2.253.637
2.321.246
2.366.319
2.411.392
4.263.494
4.391.399
4.476.669
4.561.939
7.030.698
7.241.619
7.382.233
7.522.847
2.653.105
2.732.698
2.785.761
2.838.823
4.341.445
4.471.688
4.558.517
4.645.346
6.975.048
7.184.299
7.323.800
7.463.301
2.840.357
2.925.568
2.982.375
3.039.182
4.876.913
5.023.221
5.120.759
5.218.297
8.438.292
8.691.440
8.860.206
9.028.972

RINGAN
SEDANG
BERAT

RINGAN
SEDANG
BERAT
109
E-4-13-i
110
E-4-13-ii
111
E-4-13-iii
112
F-4-10-i
SCHIZOFRENIA RINGAN
3.472.874
3.577.060
3.646.518
3.715.975
113
F-4-10-ii
SCHIZOFRENIA SEDANG
3.856.738
3.972.440
4.049.575
4.126.710
114
F-4-10-iii
SCHIZOFRENIA BERAT
5.709.986
5.881.286
5.995.485
6.109.685
115
F-4-11-i
3.201.149
3.297.183
3.361.206
3.425.229
116
F-4-11-ii
3.729.642
3.841.531
3.916.124
3.990.717
117
F-4-11-iii
DEPRESI MAYOR BERAT
4.782.764
4.926.247
5.021.902
5.117.558
1.563.232
1.610.129
1.641.394
1.672.659
2.066.323
2.128.312
2.169.639
2.210.965
4.482.540
4.617.016
4.706.667
4.796.318

IMPULSE RINGAN
IMPULSE SEDANG
IMPULSE BERAT
118
F-4-12-i
119
F-4-12-ii
120
F-4-12-iii
121
F-4-13-i
2.587.014
2.664.625
2.716.365
2.768.105
122
F-4-13-ii
3.425.872
3.528.648
3.597.166
3.665.683
123
F-4-13-iii
4.417.224
4.549.741
4.638.086
4.726.430
124
F-4-14-i
DEPRESI RINGAN
1.810.910
1.865.238
1.901.456
1.937.674
125
F-4-14-ii
DEPRESI SEDANG
2.322.860
2.392.545
2.439.003
2.485.460
126
F-4-14-iii
DEPRESI BERAT
3.125.511
3.219.276
3.281.787
3.344.297
127
F-4-15-i
2.153.069
2.217.661
2.260.722
2.303.784
128
F-4-15-ii
3.031.076
3.122.008
3.182.629
3.243.251
129
F-4-15-iii
3.811.966
3.926.325
4.002.565
4.078.804
- 352 No
Kode
INA-CBG
130
F-4-16-i
131
F-4-16-ii
132
F-4-16-iii
133
F-4-17-i
134
F-4-17-ii
135
F-4-17-iii
136
F-4-18-i
137
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.637.290
4.776.408
4.869.154
4.961.900
5.390.733
5.552.455
5.660.270
5.768.084
7.195.729
7.411.601
7.555.515
7.699.430
977.686
1.007.016
1.026.570
1.046.124
2.865.503
2.951.468
3.008.779
3.066.089
3.057.281
3.149.000
3.210.145
3.271.291
4.019.446
4.140.030
4.220.419
4.300.808
F-4-18-ii
4.422.526
4.555.202
4.643.652
4.732.103
138
F-4-18-iii
6.817.710
7.022.241
7.158.595
7.294.949
139
F-4-19-i
3.082.536
3.175.012
3.236.663
3.298.314
140
F-4-19-ii
3.947.267
4.065.685
4.144.630
4.223.575
141
F-4-19-iii
4.914.400
5.061.832
5.160.120
5.258.408
142
G-1-01-i
8.948.725
9.217.187
9.396.162
9.575.136
143
G-1-01-ii
15.146.796
15.601.200
15.904.136
16.207.072
144
G-1-01-iii
29.322.505
30.202.181
30.788.631
31.375.081
145
G-1-10-i
4.890.714
5.037.436
5.135.250
5.233.064
146
G-1-10-ii
6.904.473
7.111.607
7.249.696
7.387.786
147
G-1-10-iii
8.183.275
8.428.773
8.592.439
8.756.104
148
G-1-11-i
5.641.585
5.810.832
5.923.664
6.036.496
149
G-1-11-ii
11.585.419
11.932.982
12.164.690
12.396.399
150
G-1-11-iii
24.258.815
24.986.579
25.471.756
25.956.932
151
G-1-12-i
4.387.491
4.519.116
4.606.865
4.694.615
152
G-1-12-ii
10.044.723
10.346.065
10.546.959
10.747.854
153
G-1-12-iii
17.294.135
17.812.959
18.158.842
18.504.725
154
G-1-13-i
1.297.776
1.336.709
1.362.665
1.388.620
155
G-1-13-ii
3.485.683
3.590.253
3.659.967
3.729.681
156
G-1-13-iii
7.865.168
8.101.123
8.258.427
8.415.730
5.528.612
5.694.470
5.805.042
5.915.614
7.469.336
7.693.416
7.842.802
7.992.189
18.287.789
18.836.423
19.202.179
19.567.935

RINGAN
SEDANG
BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

RINGAN
SEDANG
BERAT
157
G-1-20-i
158
G-1-20-ii
159
G-1-20-iii
160
G-1-30-i
8.660.730
8.920.552
9.093.766
9.266.981
161
G-1-30-ii
22.605.335
23.283.495
23.735.602
24.187.708
162
G-1-30-iii
29.100.052
29.973.053
30.555.054
31.137.055
- 353 No
Kode
INA-CBG
163
G-4-10-i
164
G-4-10-ii
165
G-4-10-iii
166
G-4-11-i
167
G-4-11-ii
168
G-4-11-iii
169
G-4-12-i
170
G-4-12-ii
171
G-4-12-iii
172
G-4-13-i
173
G-4-13-ii
174
G-4-13-iii
175
G-4-14-i
176
G-4-14-ii
177
G-4-14-iii
178
G-4-15-i
179
G-4-15-ii
180
G-4-15-iii
181
G-4-16-i
182
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.554.935
3.661.583
3.732.682
3.803.780
4.147.424
4.271.847
4.354.795
4.437.744
6.938.884
7.147.051
7.285.828
7.424.606
5.229.676
5.386.566
5.491.160
5.595.753
6.066.424
6.248.417
6.369.746
6.491.074
8.890.449
9.157.163
9.334.972
9.512.781
3.911.337
4.028.678
4.106.904
4.185.131
4.928.285
5.076.134
5.174.699
5.273.265
7.157.748
7.372.480
7.515.635
7.658.790
2.176.242
2.241.529
2.285.054
2.328.579
3.376.680
3.477.980
3.545.513
3.613.047
3.991.715
4.111.466
4.191.300
4.271.135
3.980.022
4.099.423
4.179.023
4.258.624
6.548.479
6.744.934
6.875.903
7.006.873
8.198.846
8.444.811
8.608.788
8.772.765
2.894.297
2.981.126
3.039.012
3.096.897
3.669.317
3.779.396
3.852.782
3.926.169
5.554.365
5.720.996
5.832.083
5.943.170
2.411.914
2.484.271
2.532.510
2.580.748
G-4-16-ii
3.607.039
3.715.250
3.787.391
3.859.532
183
G-4-16-iii
6.546.132
6.742.516
6.873.438
7.004.361
184
G-4-17-i
3.774.752
3.887.995
3.963.490
4.038.985
185
G-4-17-ii
4.684.634
4.825.173
4.918.866
5.012.558
186
G-4-17-iii
7.851.485
8.087.030
8.244.059
8.401.089
187
G-4-18-i
2.894.297
2.981.126
3.039.012
3.096.897
188
G-4-18-ii
4.544.713
4.681.054
4.771.948
4.862.843
189
G-4-18-iii
4.814.660
4.959.100
5.055.393
5.151.687
190
G-4-19-i
2.639.955
2.719.153
2.771.952
2.824.752
191
G-4-19-ii
4.888.068
5.034.710
5.132.471
5.230.233
192
G-4-19-iii
7.291.446
7.510.189
7.656.018
7.801.847

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
DEGENERATIF RINGAN
DEGENERATIF SEDANG
DEGENERATIF BERAT
RINGAN
SEDANG
BERAT
TRAUMATIK RINGAN
TRAUMATIK SEDANG
TRAUMATIK BERAT
DENGAN INFARK BERAT
TANPA INFARK RINGAN
TANPA INFARK SEDANG
TANPA INFARK BERAT

PERIFER RINGAN
PERIFER SEDANG
PERIFER BERAT
PERSARAFAN RINGAN
PERSARAFAN SEDANG
PERSARAFAN BERAT
SEDANG
- 354 No
Kode
INA-CBG
193
G-4-20-i
194
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.688.340
1.738.990
1.772.757
1.806.524
G-4-20-ii
2.397.444
2.469.368
2.517.317
2.565.265
195
G-4-20-iii
4.088.204
4.210.850
4.292.614
4.374.378
196
G-4-21-i
2.142.517
2.206.792
2.249.643
2.292.493
197
G-4-21-ii
4.437.367
4.570.488
4.659.235
4.747.982
198
G-4-21-iii
5.227.741
5.384.573
5.489.128
5.593.683
199
G-4-22-i
1.929.531
1.987.417
2.026.008
2.064.598
200
G-4-22-ii
2.411.914
2.484.271
2.532.510
2.580.748
201
G-4-22-iii
2.767.096
2.850.109
2.905.451
2.960.793
202
G-4-23-i
1.929.531
1.987.417
2.026.008
2.064.598
203
G-4-23-ii
2.411.914
2.484.271
2.532.510
2.580.748
204
G-4-23-iii
3.447.660
3.551.090
3.620.043
3.688.996
205
G-4-24-i
1.929.531
1.987.417
2.026.008
2.064.598
206
G-4-24-ii
2.411.914
2.484.271
2.532.510
2.580.748
207
G-4-24-iii
TRAUMA KEPALA BERAT
5.068.376
5.220.427
5.321.795
5.423.162
208
G-4-25-i
GEGAR OTAK RINGAN
1.929.531
1.987.417
2.026.008
2.064.598
209
G-4-25-ii
GEGAR OTAK SEDANG
2.411.914
2.484.271
2.532.510
2.580.748
210
G-4-25-iii
GEGAR OTAK BERAT
3.011.733
3.102.085
3.162.319
3.222.554
211
G-4-26-i
3.184.432
3.279.965
3.343.654
3.407.343
212
G-4-26-ii
3.611.253
3.719.590
3.791.815
3.864.040
213
G-4-26-iii
6.445.609
6.638.977
6.767.889
6.896.801
214
H-1-20-i
3.037.341
3.128.461
3.189.208
3.249.955
215
H-1-20-ii

SEDANG
5.538.935
5.705.103
5.815.882
5.926.661
216
H-1-20-iii
7.532.606
7.758.584
7.909.236
8.059.888
217
H-1-30-i
2.973.846
3.063.062
3.122.539
3.182.015
218
H-1-30-ii
3.390.185
3.491.890
3.559.694
3.627.498
219
H-1-30-iii
5.656.401
5.826.093
5.939.221
6.052.349
220
H-4-10-i
2.894.297
2.981.126
3.039.012
3.096.897
221
H-4-10-ii
4.823.828
4.968.543
5.065.019
5.161.496
222
H-4-10-iii
7.864.264
8.100.192
8.257.477
8.414.763
223
H-4-11-i
2.158.175
2.222.921
2.266.084
2.309.248
224
H-4-11-ii
2.382.211
2.453.678
2.501.322
2.548.966
225
H-4-11-iii
3.148.599
3.243.057
3.306.029
3.369.001
226
H-4-12-i
2.994.382
3.084.214
3.144.101
3.203.989

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)

RINGAN
SEDANG
- 355 No
Kode
INA-CBG
227
H-4-12-ii
228
H-4-12-iii
229
I-1-01-i
230
I-1-01-ii
231
I-1-01-iii
232
I-1-02-i
233
I-1-02-ii
234
I-1-02-iii
235
I-1-03-i
236
I-1-03-ii
237
I-1-03-iii
238
I-1-04-i
239
I-1-04-ii
240
I-1-04-iii
241
I-1-05-i
242
I-1-05-ii
243
I-1-05-iii
244
I-1-06-i
245
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.056.087
4.177.769
4.258.891
4.340.013
6.767.304
6.970.323
7.105.669
7.241.015
41.627.323
42.876.143
43.708.689
44.541.235
42.543.341
43.819.641
44.670.508
45.521.375
67.153.848
69.168.463
70.511.540
71.854.617
23.094.599
23.787.437
24.249.329
24.711.221
29.792.033
30.685.794
31.281.634
31.877.475
36.720.412
37.822.025
38.556.433
39.290.841
14.222.476
14.649.150
14.933.599
15.218.049
19.494.351
20.079.182
20.469.069
20.858.956
28.591.715
29.449.467
30.021.301
30.593.135
19.001.648
19.571.697
19.951.730
20.331.763
24.407.954
25.140.192
25.628.351
26.116.511
52.032.690
53.593.670
54.634.324
55.674.978
30.566.381
31.483.372
32.094.700
32.706.028
36.679.657
37.780.047
38.513.640
39.247.233
50.470.977
51.985.106
52.994.526
54.003.945
15.779.013
16.252.383
16.567.963
16.883.544
I-1-06-ii
23.814.276
24.528.704
25.004.989
25.481.275
246
I-1-06-iii
27.994.318
28.834.147
29.394.034
29.953.920
247
I-1-07-i
20.750.596
21.373.114
21.788.126
22.203.138
248
I-1-07-ii
25.600.076
26.368.078
26.880.080
27.392.082
249
I-1-07-iii
27.929.517
28.767.402
29.325.993
29.884.583
250
I-1-11-i
3.947.269
4.065.688
4.144.633
4.223.578
251
I-1-11-ii
4.388.969
4.520.638
4.608.417
4.696.197
252
I-1-11-iii
5.840.380
6.015.591
6.132.399
6.249.206
253
I-1-12-i
11.046.799
11.378.203
11.599.139
11.820.075
254
I-1-12-ii
15.327.949
15.787.788
16.094.347
16.400.906
255
I-1-12-iii
21.378.871
22.020.237
22.447.815
22.875.392

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
KATETERISASI RINGAN
KATETERISASI SEDANG
KATETERISASI BERAT
RINGAN
SEDANG
BERAT

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
- 356 No
Kode
INA-CBG
256
I-1-13-i
257
I-1-13-ii
258
I-1-13-iii
259
I-1-14-i
260
I-1-14-ii
261
I-1-14-iii
262
I-1-15-i
263
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
6.498.117
6.693.061
6.823.023
6.952.985
7.560.161
7.786.966
7.938.169
8.089.372
15.092.752
15.545.535
15.847.390
16.149.245
23.773.852
24.487.067
24.962.544
25.438.021
29.547.502
30.433.927
31.024.877
31.615.827
38.717.416
39.878.938
40.653.287
41.427.635
5.101.713
5.254.764
5.356.798
5.458.833
I-1-15-ii
13.646.046
14.055.427
14.328.348
14.601.269
264
I-1-15-iii
70.633.971
72.752.990
74.165.669
75.578.349
265
I-1-16-i
10.188.794
10.494.457
10.698.233
10.902.009
266
I-1-16-ii
26.490.863
27.285.589
27.815.407
28.345.224
267
I-1-16-iii
30.556.561
31.473.258
32.084.389
32.695.520
268
I-1-17-i
3.578.486
3.685.840
3.757.410
3.828.980
269
I-1-17-ii
7.412.341
7.634.711
7.782.958
7.931.205
270
I-1-17-iii
42.972.245
44.261.412
45.120.857
45.980.302
271
I-1-20-i
5.783.324
5.956.824
6.072.490
6.188.157
272
I-1-20-ii
9.554.954
9.841.602
10.032.702
10.223.801
273
I-1-20-iii
19.348.433
19.928.886
20.315.855
20.702.823
274
I-1-30-i
11.559.239
11.906.017
12.137.201
12.368.386
275
I-1-30-ii
24.045.553
24.766.920
25.247.831
25.728.742
276
I-1-30-iii
37.261.874
38.379.730
39.124.968
39.870.205
277
I-1-40-i
17.023.365
17.534.066
17.874.533
18.215.000
278
I-1-40-ii
23.066.864
23.758.870
24.220.207
24.681.545
279
I-1-40-iii
28.529.635
29.385.524
29.956.117
30.526.710
280
I-4-10-i
4.950.889
5.099.416
5.198.433
5.297.451
281
I-4-10-ii
7.817.543
8.052.069
8.208.420
8.364.771
282
I-4-10-iii
11.277.487
11.615.812
11.841.362
12.066.911
283
I-4-11-i
5.870.460
6.046.574
6.163.983
6.281.392
284
I-4-11-ii
7.235.742
7.452.814
7.597.529
7.742.244

KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

DARAH VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
- 357 No
Kode
INA-CBG
285
I-4-11-iii
286
I-4-12-i
287
288
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
11.739.972
12.092.171
12.326.970
12.561.770
5.141.913
5.296.170
5.399.008
5.501.846
I-4-12-ii
7.337.495
7.557.619
7.704.369
7.851.119
I-4-12-iii
8.901.413
9.168.456
9.346.484
9.524.512
4.618.851
4.757.417
4.849.794
4.942.171
6.710.248
6.911.555
7.045.760
7.179.965
12.541.952
12.918.211
13.169.050
13.419.889

VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
289
I-4-13-i
290
I-4-13-ii
291
I-4-13-iii
292
I-4-14-i
2.872.499
2.958.674
3.016.124
3.073.574
293
I-4-14-ii
3.361.248
3.462.086
3.529.311
3.596.536
294
I-4-14-iii
5.208.817
5.365.081
5.469.257
5.573.434
3.859.062
3.974.834
4.052.015
4.129.197
6.049.992
6.231.492
6.352.492
6.473.492
6.895.536
7.102.402
7.240.312
7.378.223

295
I-4-15-i
296
I-4-15-ii
297
I-4-15-iii
298
I-4-16-i
2.894.297
2.981.126
3.039.012
3.096.897
299
I-4-16-ii
4.690.658
4.831.378
4.925.191
5.019.004
300
I-4-16-iii
5.909.396
6.086.678
6.204.866
6.323.054
301
I-4-17-i
HIPERTENSI RINGAN
2.836.761
2.921.864
2.978.599
3.035.334
302
I-4-17-ii
HIPERTENSI SEDANG
3.869.858
3.985.954
4.063.351
4.140.748
303
I-4-17-iii
HIPERTENSI BERAT
4.523.087
4.658.779
4.749.241
4.839.703
4.177.734
4.303.066
4.386.620
4.470.175
6.400.008
6.592.009
6.720.009
6.848.009
8.628.237
8.887.084
9.059.649
9.232.213
3.269.624
3.367.713
3.433.105
3.498.498
5.307.761
5.466.994
5.573.149
5.679.304
6.079.871
6.262.267
6.383.865
6.505.462

RINGAN
SEDANG
KONGENITAL BERAT
RINGAN
SEDANG
BERAT
304
I-4-18-i
305
I-4-18-ii
306
I-4-18-iii
307
I-4-19-i
308
I-4-19-ii
309
I-4-19-iii
310
I-4-20-i
3.968.152
4.087.197
4.166.560
4.245.923
311
I-4-20-ii
4.571.608
4.708.756
4.800.188
4.891.620
312
I-4-20-iii
6.067.284
6.249.303
6.370.648
6.491.994
313
I-4-21-i
5.277.000
5.435.310
5.540.850
5.646.390
314
I-4-21-ii
6.582.715
6.780.197
6.911.851
7.043.505
315
I-4-21-iii
8.980.219
9.249.626
9.429.230
9.608.835
316
I-4-22-i
3.135.488
3.229.553
3.292.263
3.354.972
317
I-4-22-ii
3.613.021
3.721.411
3.793.672
3.865.932
- 358 No
Kode
INA-CBG
318
I-4-22-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.271.299
5.429.438
5.534.864
5.640.290
2.375.309
2.446.568
2.494.075
2.541.581
2.916.332
3.003.822
3.062.149
3.120.475
5.698.247
5.869.195
5.983.160
6.097.125
3.102.574
3.195.651
3.257.702
3.319.754
7.746.268
7.978.656
8.133.581
8.288.507
9.793.757
10.087.569
10.283.444
10.479.320
24.996.483
25.746.377
26.246.307
26.746.236
26.703.652
27.504.761
28.038.834
28.572.907
45.623.346
46.992.046
47.904.513
48.816.980
12.777.706
13.161.037
13.416.592
13.672.146
13.688.328
14.098.978
14.372.744
14.646.511
20.227.448
20.834.272
21.238.821
21.643.370
4.986.046
5.135.627
5.235.348
5.335.069
12.043.112
12.404.406
12.645.268
12.886.130
21.323.810
21.963.525
22.390.001
22.816.477
4.309.539
4.438.825
4.525.016
4.611.207
6.267.884
6.455.921
6.581.278
6.706.636
9.424.962
9.707.711
9.896.210
10.084.709
2.906.160
2.993.345
3.051.468
3.109.591
12.996.234
13.386.121
13.646.046
13.905.971
39.196.071
40.371.954
41.155.875
41.939.796
319
I-4-23-i
320
I-4-23-ii
321
I-4-23-iii
322
I-4-24-i
323
I-4-24-ii
324
I-4-24-iii
325
J-1-01-i
326
J-1-01-ii
327
J-1-01-iii
328
J-1-02-i
329
J-1-02-ii
330
J-1-02-iii
331
J-1-10-i
332
J-1-10-ii
333
J-1-10-iii
334
J-1-20-i
335
J-1-20-ii
336
J-1-20-iii
337
J-1-30-i
338
J-1-30-ii
339
J-1-30-iii
340
J-4-10-i
3.062.731
3.154.613
3.215.868
3.277.123
341
J-4-10-ii
4.379.338
4.510.718
4.598.305
4.685.892
342
J-4-10-iii
6.625.285
6.824.043
6.956.549
7.089.055
343
J-4-11-i
2.116.008
2.179.489
2.221.809
2.264.129
344
J-4-11-ii
2.945.435
3.033.798
3.092.707
3.151.616
345
J-4-11-iii
4.220.884
4.347.510
4.431.928
4.516.346
346
J-4-12-i
EMBOLI PARU RINGAN
2.954.826
3.043.471
3.102.568
3.161.664
347
J-4-12-ii
EMBOLI PARU SEDANG
3.826.399
3.941.191
4.017.719
4.094.247
348
J-4-12-iii
EMBOLI PARU BERAT
5.109.769
5.263.062
5.365.258
5.467.453
- 359 No
Kode
INA-CBG
349
J-4-13-i
350
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.984.555
5.134.092
5.233.783
5.333.474
J-4-13-ii
7.327.296
7.547.115
7.693.661
7.840.207
351
J-4-13-iii
11.913.087
12.270.480
12.508.741
12.747.003
352
J-4-14-i
TUMOR PARU RINGAN
3.396.817
3.498.721
3.566.658
3.634.594
353
J-4-14-ii
TUMOR PARU SEDANG
5.690.133
5.860.837
5.974.640
6.088.442
354
J-4-14-iii
TUMOR PARU BERAT
6.765.279
6.968.237
7.103.543
7.238.849
2.973.784
3.062.997
3.122.473
3.181.949
4.187.264
4.312.882
4.396.628
4.480.373
5.261.834
5.419.689
5.524.925
5.630.162
2.411.914
2.484.271
2.532.510
2.580.748
3.495.946
3.600.824
3.670.743
3.740.662
6.091.175
6.273.910
6.395.733
6.517.557

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
355
J-4-15-i
356
J-4-15-ii
357
J-4-15-iii
358
J-4-16-i
359
J-4-16-ii
360
J-4-16-iii
361
J-4-17-i
2.434.618
2.507.657
2.556.349
2.605.042
362
J-4-17-ii
3.304.484
3.403.618
3.469.708
3.535.797
363
J-4-17-iii
5.320.998
5.480.628
5.587.048
5.693.468
364
J-4-18-i
1.929.531
1.987.417
2.026.008
2.064.598
365
J-4-18-ii
2.653.105
2.732.698
2.785.761
2.838.823
366
J-4-18-iii
2.793.557
2.877.364
2.933.235
2.989.106
367
J-4-19-i
3.376.680
3.477.980
3.545.513
3.613.047
368
J-4-19-ii
4.187.234
4.312.851
4.396.595
4.480.340
369
J-4-19-iii
6.045.674
6.227.044
6.347.957
6.468.871
370
J-4-20-i
3.405.746
3.507.918
3.576.033
3.644.148
371
J-4-20-ii
4.510.769
4.646.092
4.736.307
4.826.522
372
J-4-20-iii
9.307.285
9.586.504
9.772.650
9.958.795
1.929.531
1.987.417
2.026.008
2.064.598
4.760.506
4.903.321
4.998.531
5.093.741
6.790.038
6.993.739
7.129.540
7.265.341
5.198.494
5.354.448
5.458.418
5.562.388
7.945.010
8.183.361
8.342.261
8.501.161
9.304.975
9.584.124
9.770.224
9.956.323
4.895.138
5.041.992
5.139.895
5.237.798
6.426.726
6.619.527
6.748.062
6.876.596
16.309.765
16.799.058
17.125.253
17.451.448
373
J-4-21-i
374
J-4-21-ii
375
J-4-21-iii
376
K-1-10-i
377
K-1-10-ii
378
K-1-10-iii
379
K-1-11-i
380
K-1-11-ii
381
K-1-11-iii

USUS BESAR (RINGAN)
USUS BESAR (SEDANG)
USUS BESAR (BERAT)
RINGAN
SEDANG
- 360 No
Kode
INA-CBG
382
K-1-12-i
383
K-1-12-ii
384
K-1-12-iii
385
K-1-13-i
386
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.633.210
2.712.206
2.764.870
2.817.534
3.431.887
3.534.843
3.603.481
3.672.119
6.826.744
7.031.547
7.168.082
7.304.616
2.990.965
3.080.694
3.140.514
3.200.333
K-1-13-ii
5.224.357
5.381.088
5.485.575
5.590.062
387
K-1-13-iii
5.587.262
5.754.879
5.866.625
5.978.370
388
K-1-14-i
4.833.577
4.978.584
5.075.256
5.171.927
389
K-1-14-ii
5.677.584
5.847.911
5.961.463
6.075.014
390
K-1-14-iii
13.979.857
14.399.253
14.678.850
14.958.447
391
K-1-20-i
9.378.557
9.659.914
9.847.485
10.035.056
392
K-1-20-ii
13.089.992
13.482.692
13.744.492
14.006.292
393
K-1-20-iii
27.960.842
28.799.667
29.358.884
29.918.101
394
K-1-30-i
6.173.433
6.358.636
6.482.105
6.605.573
395
K-1-30-ii
10.396.987
10.708.897
10.916.837
11.124.776
396
K-1-30-iii
17.732.357
18.264.327
18.618.974
18.973.621
397
K-1-40-i
6.201.959
6.388.017
6.512.057
6.636.096
398
K-1-40-ii
6.824.640
7.029.379
7.165.871
7.302.364
399
K-1-40-iii
11.318.008
11.657.548
11.883.908
12.110.268
400
K-1-50-i
4.730.598
4.872.516
4.967.128
5.061.740
401
K-1-50-ii
6.126.348
6.310.138
6.432.665
6.555.192
402
K-1-50-iii
PROSEDUR ANAL BERAT
8.697.784
8.958.718
9.132.674
9.306.629
403
K-4-10-i
3.583.088
3.690.580
3.762.242
3.833.904
404
K-4-10-ii
4.287.375
4.415.996
4.501.744
4.587.491
405
K-4-10-iii
16.211.704
16.698.056
17.022.290
17.346.524
406
K-4-11-i
1.929.531
1.987.417
2.026.008
2.064.598
407
K-4-11-ii
2.894.297
2.981.126
3.039.012
3.096.897
408
K-4-11-iii
5.259.980
5.417.779
5.522.979
5.628.179
409
K-4-12-i
1.929.531
1.987.417
2.026.008
2.064.598
410
K-4-12-ii
3.156.927
3.251.635
3.314.773
3.377.912
411
K-4-12-iii
7.576.400
7.803.692
7.955.220
8.106.748
412
K-4-13-i
2.894.297
2.981.126
3.039.012
3.096.897
413
K-4-13-ii
3.748.827
3.861.292
3.936.268
4.011.245


RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)

(RINGAN)
(SEDANG)
- 361 No
Kode
INA-CBG
414
K-4-13-iii
415
K-4-14-i
416
K-4-14-ii
417
K-4-14-iii
418
K-4-15-i
419
K-4-15-ii
420
K-4-15-iii
421
K-4-16-i
422
423
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
6.131.440
6.315.383
6.438.012
6.560.641
2.411.914
2.484.271
2.532.510
2.580.748
3.264.274
3.362.202
3.427.487
3.492.773
4.937.525
5.085.651
5.184.402
5.283.152
2.411.914
2.484.271
2.532.510
2.580.748
4.535.056
4.671.108
4.761.809
4.852.510
6.452.568
6.646.146
6.775.197
6.904.248
2.411.914
2.484.271
2.532.510
2.580.748
K-4-16-ii
2.894.297
2.981.126
3.039.012
3.096.897
K-4-16-iii
3.868.955
3.985.024
4.062.403
4.139.782
1.929.531
1.987.417
2.026.008
2.064.598
3.083.041
3.175.532
3.237.193
3.298.854
4.103.213
4.226.309
4.308.374
4.390.438
2.106.210
2.169.396
2.211.520
2.253.645
3.280.396
3.378.808
3.444.416
3.510.023
3.814.342
3.928.772
4.005.059
4.081.346
21.623.804
22.272.518
22.704.994
23.137.470
22.419.062
23.091.634
23.540.015
23.988.397
34.464.504
35.498.439
36.187.729
36.877.019
9.097.364
9.370.285
9.552.232
9.734.179
14.206.805
14.633.009
14.917.145
15.201.281
14.983.747
15.433.259
15.732.934
16.032.609
3.960.153
4.078.958
4.158.161
4.237.364
8.913.116
9.180.510
9.358.772
9.537.034
14.914.907
15.362.355
15.660.653
15.958.951

RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
424
K-4-17-i
425
K-4-17-ii
426
K-4-17-iii
427
K-4-18-i
428
K-4-18-ii
429
K-4-18-iii
430
L-1-20-i
431
L-1-20-ii
432
L-1-20-iii
433
L-1-30-i
434
L-1-30-ii
435
L-1-30-iii
436
L-1-40-i
437
L-1-40-ii
438
L-1-40-iii
439
L-1-50-i
6.498.117
6.693.061
6.823.023
6.952.985
440
L-1-50-ii
11.696.611
12.047.509
12.281.441
12.515.373
441
L-1-50-iii
14.142.857
14.567.143
14.850.000
15.132.857
442
L-4-10-i
2.894.297
2.981.126
3.039.012
3.096.897
443
L-4-10-ii
3.634.675
3.743.715
3.816.408
3.889.102
444
L-4-10-iii
7.480.559
7.704.976
7.854.587
8.004.198
445
L-4-11-i
2.997.901
3.087.838
3.147.796
3.207.754
- 362 No
Kode
INA-CBG
446
L-4-11-ii
447
L-4-11-iii
448
L-4-12-i
449
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.107.071
4.230.284
4.312.425
4.394.566
11.137.864
11.472.000
11.694.757
11.917.515
2.959.456
3.048.240
3.107.429
3.166.618
L-4-12-ii
4.650.595
4.790.113
4.883.125
4.976.137
450
L-4-12-iii
7.531.472
7.757.416
7.908.045
8.058.675
451
L-4-13-i
1.989.486
2.049.171
2.088.961
2.128.750
452
L-4-13-ii
2.293.995
2.362.815
2.408.695
2.454.575
453
L-4-13-iii
3.441.172
3.544.407
3.613.230
3.682.054
454
L-4-14-i
1.929.531
1.987.417
2.026.008
2.064.598
455
L-4-14-ii
2.894.297
2.981.126
3.039.012
3.096.897
456
L-4-14-iii
4.955.787
5.104.460
5.203.576
5.302.692
457
M-1-01-i
11.554.462
11.901.095
12.132.185
12.363.274
458
M-1-01-ii
12.896.648
13.283.548
13.541.481
13.799.414
459
M-1-01-iii
18.116.297
18.659.786
19.022.112
19.384.438
460
M-1-02-i
7.381.723
7.603.174
7.750.809
7.898.443
461
M-1-02-ii
12.119.385
12.482.967
12.725.354
12.967.742
462
M-1-02-iii
21.947.651
22.606.080
23.045.033
23.483.986
19.833.656
20.428.666
20.825.339
21.222.012
23.823.053
24.537.744
25.014.205
25.490.666
24.742.172
25.484.437
25.979.280
26.474.124
4.869.501
5.015.586
5.112.976
5.210.366
6.242.650
6.429.929
6.554.782
6.679.635
7.811.500
8.045.845
8.202.075
8.358.305
7.585.748
7.813.320
7.965.035
8.116.750
8.767.092
9.030.104
9.205.446
9.380.788
14.932.745
15.380.727
15.679.382
15.978.037
9.283.122
9.561.616
9.747.278
9.932.941
12.436.483
12.809.577
13.058.307
13.307.037
25.334.295
26.094.324
26.601.010
27.107.695
5.233.341
5.390.342
5.495.008
5.599.675
19.446.962
20.030.371
20.419.310
20.808.249
24.256.933
24.984.641
25.469.780
25.954.919
463
M-1-03-i
464
M-1-03-ii
465
M-1-03-iii
466
M-1-04-i
467
M-1-04-ii
468
M-1-04-iii
469
M-1-05-i
470
M-1-05-ii
471
M-1-05-iii
472
M-1-07-i
473
M-1-07-ii
474
M-1-07-iii
475
M-1-10-i
476
M-1-10-ii
477
M-1-10-iii


TULANG WAJAH RINGAN
TULANG WAJAH SEDANG
TULANG WAJAH BERAT
- 363 No
Kode
INA-CBG
478
M-1-20-i
479
M-1-20-ii
480
M-1-20-iii
481
M-1-30-i
482
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.177.127
5.332.440
5.435.983
5.539.526
7.383.653
7.605.162
7.752.836
7.900.509
14.364.323
14.795.253
15.082.539
15.369.826
3.096.696
3.189.597
3.251.531
3.313.464
M-1-30-ii
6.398.561
6.590.518
6.718.489
6.846.460
483
M-1-30-iii
PROSEDUR KAKI BERAT
9.545.304
9.831.663
10.022.569
10.213.475
484
M-1-40-i
3.468.831
3.572.896
3.642.272
3.711.649
485
M-1-40-ii
6.385.077
6.576.629
6.704.330
6.832.032
486
M-1-40-iii
11.173.884
11.509.100
11.732.578
11.956.056
487
M-1-50-i
4.143.927
4.268.245
4.351.123
4.434.002
488
M-1-50-ii
8.341.822
8.592.077
8.758.914
8.925.750
489
M-1-50-iii
12.770.153
13.153.258
13.408.661
13.664.064
3.127.357
3.221.178
3.283.725
3.346.272
6.260.990
6.448.819
6.574.039
6.699.259
10.896.337
11.223.227
11.441.153
11.659.080
4.189.401
4.315.083
4.398.871
4.482.659
8.548.453
8.804.907
8.975.876
9.146.845
13.781.140
14.194.574
14.470.196
14.745.819


RINGAN
SEDANG
BERAT

SELAIN KAKI (BERAT)
490
M-1-60-i
491
M-1-60-ii
492
M-1-60-iii
493
M-1-70-i
494
M-1-70-ii
495
M-1-70-iii
496
M-1-80-i
3.375.524
3.476.789
3.544.300
3.611.810
497
M-1-80-ii
5.103.101
5.256.194
5.358.257
5.460.319
498
M-1-80-iii
11.748.661
12.101.121
12.336.095
12.571.068
499
M-4-10-i
2.369.957
2.441.055
2.488.454
2.535.854
500
M-4-10-ii
3.554.935
3.661.583
3.732.682
3.803.780
501
M-4-10-iii
FRAKTUR FEMUR BERAT
6.926.012
7.133.792
7.272.312
7.410.833
502
M-4-11-i
2.962.446
3.051.319
3.110.568
3.169.817
503
M-4-11-ii
6.490.641
6.685.360
6.815.173
6.944.986
504
M-4-11-iii
11.520.736
11.866.358
12.096.772
12.327.187
505
M-4-12-i
2.369.957
2.441.055
2.488.454
2.535.854
506
M-4-12-ii
4.312.133
4.441.497
4.527.740
4.613.983
507
M-4-12-iii
7.789.951
8.023.649
8.179.448
8.335.247
508
M-4-13-i
3.946.492
4.064.886
4.143.816
4.222.746

PANGGUL RINGAN
PANGGUL SEDANG
PANGGUL BERAT
PELVIS RINGAN
PELVIS SEDANG
PELVIS BERAT
- 364 No
Kode
INA-CBG
509
M-4-13-ii
510
M-4-13-iii
511
M-4-14-i
512
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.924.891
6.102.638
6.221.136
6.339.634
11.739.824
12.092.019
12.326.815
12.561.612
4.493.283
4.628.081
4.717.947
4.807.813
M-4-14-ii
5.550.768
5.717.291
5.828.307
5.939.322
513
M-4-14-iii
OSTEOMIELITIS BERAT
8.314.453
8.563.886
8.730.175
8.896.464
514
M-4-15-i
2.667.466
2.747.490
2.800.839
2.854.188
515
M-4-15-ii
3.556.846
3.663.551
3.734.688
3.805.825
516
M-4-15-iii
10.072.315
10.374.485
10.575.931
10.777.377
517
M-4-16-i
2.962.446
3.051.319
3.110.568
3.169.817
518
M-4-16-ii
4.739.913
4.882.111
4.976.909
5.071.707
519
M-4-16-iii
7.950.020
8.188.520
8.347.521
8.506.521
2.962.446
3.051.319
3.110.568
3.169.817
4.147.424
4.271.847
4.354.795
4.437.744
5.792.098
5.965.861
6.081.703
6.197.545
3.132.232
3.226.199
3.288.843
3.351.488
4.739.913
4.882.111
4.976.909
5.071.707
5.312.082
5.471.445
5.577.686
5.683.928
2.328.857
2.398.722
2.445.300
2.491.877
3.922.540
4.040.217
4.118.668
4.197.118
7.661.012
7.890.842
8.044.062
8.197.283
2.369.957
2.441.055
2.488.454
2.535.854
3.554.935
3.661.583
3.732.682
3.803.780
3.939.706
4.057.897
4.136.691
4.215.485
2.369.957
2.441.055
2.488.454
2.535.854
2.962.446
3.051.319
3.110.568
3.169.817
6.801.605
7.005.653
7.141.686
7.277.718

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
RINGAN
SEDANG
BERAT
ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
520
M-4-17-i
521
M-4-17-ii
522
M-4-17-iii
523
M-4-18-i
524
M-4-18-ii
525
M-4-18-iii
526
M-4-19-i
527
M-4-19-ii
528
M-4-19-iii
529
M-4-20-i
530
M-4-20-ii
531
M-4-20-iii
532
M-4-21-i
533
M-4-21-ii
534
M-4-21-iii
535
N-1-01-i
5.220.789
5.377.413
5.481.829
5.586.245
536
N-1-01-ii
7.061.000
7.272.830
7.414.050
7.555.270
537
N-1-01-iii
14.971.420
15.420.563
15.719.991
16.019.419
7.887.672
8.124.302
8.282.056
8.439.809
10.667.898
10.987.935
11.201.293
11.414.651
538
N-1-11-i
539
N-1-11-ii

RINGAN
SEDANG
- 365 No
Kode
INA-CBG
540
N-1-11-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
20.793.975
21.417.794
21.833.673
22.249.553
3.898.870
4.015.836
4.093.814
4.171.791
9.933.340
10.231.340
10.430.007
10.628.674
18.104.130
18.647.254
19.009.337
19.371.420
541
N-1-12-i
542
N-1-12-ii
543
N-1-12-iii
544
N-1-20-i
5.780.944
5.954.372
6.069.991
6.185.610
545
N-1-20-ii
11.461.557
11.805.404
12.034.635
12.263.866
546
N-1-20-iii
13.110.982
13.504.312
13.766.531
14.028.751
6.877.453
7.083.777
7.221.326
7.358.875
10.451.148
10.764.683
10.973.706
11.182.729
12.030.995
12.391.925
12.632.545
12.873.165
6.197.259
6.383.176
6.507.122
6.631.067
8.400.605
8.652.623
8.820.635
8.988.648
9.770.146
10.063.251
10.258.654
10.454.057
2.411.914
2.484.271
2.532.510
2.580.748
3.536.862
3.642.968
3.713.705
3.784.442
7.069.057
7.281.129
7.422.510
7.563.891

URIN BAWAH RINGAN
URIN BAWAH SEDANG
URIN BAWAH BERAT
RINGAN
SEDANG
BERAT
GINJAL RINGAN
GINJAL SEDANG
GINJAL BERAT
547
N-1-30-i
548
N-1-30-ii
549
N-1-30-iii
550
N-1-40-i
551
N-1-40-ii
552
N-1-40-iii
553
N-4-10-i
554
N-4-10-ii
555
N-4-10-iii
556
N-4-11-i
2.022.766
2.083.449
2.123.904
2.164.359
557
N-4-11-ii
3.418.426
3.520.978
3.589.347
3.657.715
558
N-4-11-iii
3.911.795
4.029.149
4.107.385
4.185.621
559
N-4-12-i
1.955.921
2.014.598
2.053.717
2.092.835
560
N-4-12-ii
2.894.297
2.981.126
3.039.012
3.096.897
561
N-4-12-iii
4.805.484
4.949.648
5.045.758
5.141.868
562
N-4-13-i
BATU URIN RINGAN
2.787.818
2.871.453
2.927.209
2.982.966
563
N-4-13-ii
BATU URIN SEDANG
3.361.060
3.461.892
3.529.113
3.596.335
564
N-4-13-iii
BATU URIN BERAT
8.277.370
8.525.691
8.691.238
8.856.786
1.671.332
1.721.472
1.754.898
1.788.325
2.573.640
2.650.850
2.702.322
2.753.795
4.173.624
4.298.833
4.382.306
4.465.778
2.715.437
2.796.900
2.851.208
2.905.517
565
N-4-14-i
566
N-4-14-ii
567
N-4-14-iii
568
N-4-15-i

(RINGAN)
(SEDANG)
(BERAT)
SALURAN URIN RINGAN
- 366 No
Kode
INA-CBG
569
N-4-15-ii
570
N-4-15-iii
571
N-4-16-i
572
N-4-16-ii
573
N-4-16-iii
574
O-6-10-i
575
O-6-10-ii
576
O-6-10-iii
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
584
585
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.726.424
3.838.217
3.912.745
3.987.273
4.252.522
4.380.098
4.465.148
4.550.199
2.727.162
2.808.977
2.863.521
2.918.064
3.859.062
3.974.834
4.052.015
4.129.197
8.115.034
8.358.485
8.520.786
8.683.086
3.392.085
3.493.848
3.561.690
3.629.531
3.765.732
3.878.704
3.954.018
4.029.333
4.640.657
4.779.877
4.872.690
4.965.503
2.141.468
2.205.713
2.248.542
2.291.371
3.489.080
3.593.753
3.663.534
3.733.316
5.912.908
6.090.296
6.208.554
6.326.812
2.368.296
2.439.345
2.486.711
2.534.077
2.844.317
2.929.647
2.986.533
3.043.420
3.573.477
3.680.682
3.752.151
3.823.621
1.751.211
1.803.747
1.838.771
1.873.796
O-6-13-ii
1.960.580
2.019.397
2.058.609
2.097.820
O-6-13-iii
2.438.240
2.511.387
2.560.152
2.608.917
48.481.088
49.935.521
50.905.143
51.874.764
59.987.763
61.787.396
62.987.151
64.186.906
70.408.818
72.521.082
73.929.258
75.337.435
64.326.573
66.256.370
67.542.902
68.829.433
73.789.201
76.002.877
77.478.661
78.954.445
84.309.438
86.838.721
88.524.910
90.211.098
3.249.059
3.346.530
3.411.511
3.476.493
4.548.682
4.685.142
4.776.116
4.867.090
7.165.206
7.380.162
7.523.466
7.666.770
31.776.775
32.730.078
33.365.613
34.001.149
41.239.402
42.476.584
43.301.372
44.126.160
59.126.922
60.900.730
62.083.269
63.265.807
586
P-8-01-i
587
P-8-01-ii
588
P-8-01-iii
589
P-8-02-i
590
P-8-02-ii
591
P-8-02-iii
592
P-8-03-i
593
P-8-03-ii
594
P-8-03-iii
595
P-8-04-i
596
P-8-04-ii
597
P-8-04-iii

SALURAN URIN SEDANG
SALURAN URIN BERAT
RINGAN
SEDANG
BERAT
&KURET RINGAN
KURET SEDANG
KURET BERAT

- 367 No
Kode
INA-CBG
598
P-8-05-i
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii
603
P-8-06-iii
604
P-8-07-i
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
614
P-8-11-ii
615
P-8-11-iii
616
P-8-12-i
617
P-8-12-ii
618
P-8-12-iii
619
P-8-13-i
620
P-8-13-ii
621
P-8-13-iii
622
P-8-14-i
623
P-8-14-ii
624
P-8-14-iii
625
P-8-15-i
Deskripsi (INA-CBG)
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
RINGAN
SEDANG
BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
ASPIRASI RINGAN
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
17.279.180
17.797.555
18.143.139
18.488.722
24.490.908
25.225.635
25.715.453
26.205.271
36.084.065
37.166.587
37.888.268
38.609.949
2.599.247
2.677.224
2.729.209
2.781.194
7.162.589
7.377.467
7.520.719
7.663.970
13.323.233
13.722.930
13.989.395
14.255.859
4.591.932
4.729.690
4.821.529
4.913.368
12.753.409
13.136.012
13.391.080
13.646.148
16.895.104
17.401.957
17.739.860
18.077.762
3.609.937
3.718.235
3.790.434
3.862.632
5.124.813
5.278.557
5.381.054
5.483.550
7.234.662
7.451.702
7.596.395
7.741.088
2.239.601
2.306.789
2.351.581
2.396.373
3.244.387
3.341.719
3.406.607
3.471.494
6.369.688
6.560.779
6.688.173
6.815.567
2.712.866
2.794.252
2.848.510
2.902.767
13.428.850
13.831.716
14.100.293
14.368.870
13.710.187
14.121.492
14.395.696
14.669.900
2.975.792
3.065.065
3.124.581
3.184.097
4.626.839
4.765.645
4.858.181
4.950.718
5.458.692
5.622.453
5.731.627
5.840.800
1.538.050
1.584.191
1.614.952
1.645.713
2.846.149
2.931.533
2.988.456
3.045.379
4.256.720
4.384.421
4.469.556
4.554.690
2.810.177
2.894.482
2.950.685
3.006.889
5.737.585
5.909.713
6.024.464
6.139.216
6.294.110
6.482.933
6.608.815
6.734.697
2.113.340
2.176.741
2.219.007
2.261.274
- 368 No
Kode
INA-CBG
626
P-8-15-ii
627
P-8-15-iii
628
P-8-16-i
629
P-8-16-ii
630
P-8-16-iii
631
P-8-17-i
632
P-8-17-ii
633
P-8-17-iii
634
S-4-10-i
635
S-4-10-ii
636
S-4-10-iii
637
S-4-11-i
638
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.224.012
4.350.732
4.435.212
4.519.693
4.961.756
5.110.608
5.209.844
5.309.079
1.913.073
1.970.465
2.008.726
2.046.988
2.713.775
2.795.188
2.849.464
2.903.739
3.522.613
3.628.292
3.698.744
3.769.196
1.260.331
1.298.141
1.323.348
1.348.555
4.194.009
4.319.829
4.403.709
4.487.589
8.465.340
8.719.300
8.888.606
9.057.913
1.929.531
1.987.417
2.026.008
2.064.598
2.411.914
2.484.271
2.532.510
2.580.748
3.135.074
3.229.126
3.291.828
3.354.529
1.205.957
1.242.136
1.266.255
1.290.374
S-4-11-ii
1.929.531
1.987.417
2.026.008
2.064.598
639
S-4-11-iii
2.969.501
3.058.586
3.117.976
3.177.366
640
S-4-12-i
1.447.148
1.490.563
1.519.506
1.548.449
641
S-4-12-ii
1.929.531
1.987.417
2.026.008
2.064.598
642
S-4-12-iii
3.768.527
3.881.583
3.956.953
4.032.324
1.929.531
1.987.417
2.026.008
2.064.598
3.410.978
3.513.308
3.581.527
3.649.747
6.945.186
7.153.541
7.292.445
7.431.349
1.175.628
1.210.897
1.234.409
1.257.922
2.497.428
2.572.351
2.622.299
2.672.248
4.736.013
4.878.093
4.972.814
5.067.534
889.138
915.812
933.595
951.378
1.678.107
1.728.450
1.762.012
1.795.574
2.173.538
2.238.744
2.282.215
2.325.686

ASPIRASI SEDANG
ASPIRASI BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT

PASIEN RINGAN
PASIEN SEDANG
PASIEN BERAT
643
S-4-13-i
644
S-4-13-ii
645
S-4-13-iii
646
S-4-14-i
647
S-4-14-ii
648
S-4-14-iii
649
S-4-15-i
650
S-4-15-ii
651
S-4-15-iii
652
S-4-16-i
LUKA BAKAR RINGAN
3.376.680
3.477.980
3.545.513
3.613.047
653
S-4-16-ii
LUKA BAKAR SEDANG
5.222.656
5.379.335
5.483.788
5.588.241
654
S-4-16-iii
LUKA BAKAR BERAT
9.325.862
9.605.638
9.792.155
9.978.673
1.971.799
2.030.953
2.070.389
2.109.825
2.411.914
2.484.271
2.532.510
2.580.748
3.933.102
4.051.095
4.129.757
4.208.419
655
S-4-17-i
656
S-4-17-ii
657
S-4-17-iii

- 369 No
Kode
INA-CBG
658
T-1-10-i
659
T-1-10-ii
660
T-1-10-iii
661
T-4-10-i
662
T-4-10-ii
663
T-4-10-iii
664
T-4-11-i
665
T-4-11-ii
666
T-4-11-iii
667
T-4-12-i
668
T-4-12-ii
669
T-4-12-iii
670
U-1-10-i
671
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.035.441
2.096.504
2.137.213
2.177.922
2.733.459
2.815.462
2.870.132
2.924.801
4.973.052
5.122.244
5.221.705
5.321.166
813.016
837.406
853.666
869.927
1.549.427
1.595.910
1.626.899
1.657.887
2.252.447
2.320.020
2.365.069
2.410.118
880.515
906.930
924.541
942.151
1.385.680
1.427.250
1.454.964
1.482.677
2.231.922
2.298.880
2.343.518
2.388.156
1.688.340
1.738.990
1.772.757
1.806.524
2.551.833
2.628.388
2.679.424
2.730.461
3.969.735
4.088.827
4.168.221
4.247.616
1.797.083
1.850.996
1.886.937
1.922.879
U-1-10-ii
3.667.058
3.777.070
3.850.411
3.923.752
672
U-1-10-iii
15.835.098
16.310.151
16.626.853
16.943.555
673
U-1-11-i
674
U-1-11-ii
675
U-1-11-iii
676

DOKTER RINGAN
DOKTER SEDANG
DOKTER BERAT

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
7.797.740
8.031.673
8.187.627
8.343.582
10.396.987
10.708.897
10.916.837
11.124.776
19.129.626
19.703.514
20.086.107
20.468.699
U-1-12-i
5.218.617
5.375.175
5.479.548
5.583.920
677
U-1-12-ii
11.696.611
12.047.509
12.281.441
12.515.373
678
U-1-12-iii
15.188.270
15.643.919
15.947.684
16.251.449
679
U-1-13-i
5.198.494
5.354.448
5.458.418
5.562.388
680
U-1-13-ii
6.423.293
6.615.992
6.744.458
6.872.923
681
U-1-13-iii
11.309.974
11.649.274
11.875.473
12.101.673
3.141.240
3.235.477
3.298.302
3.361.127
3.854.933
3.970.581
4.047.680
4.124.779
4.568.204
4.705.251
4.796.615
4.887.979

682
U-1-14-i
683
U-1-14-ii
684
U-1-14-iii
685
U-1-15-i
1.844.970
1.900.319
1.937.219
1.974.118
686
U-1-15-ii
2.621.574
2.700.221
2.752.652
2.805.084
687
U-1-15-iii
5.165.916
5.320.894
5.424.212
5.527.530
U-1-20-i

4.772.134
4.915.298
5.010.741
5.106.183
688
- 370 No
Kode
INA-CBG
689
U-1-20-ii
690
U-1-20-iii
691
U-1-30-i
692
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
8.494.398
8.749.230
8.919.118
9.089.006
19.135.576
19.709.643
20.092.355
20.475.066
4.093.659
4.216.468
4.298.342
4.380.215
U-1-30-ii
5.526.439
5.692.232
5.802.761
5.913.290
693
U-1-30-iii
10.396.987
10.708.897
10.916.837
11.124.776
694
U-4-10-i
3.810.512
3.924.828
4.001.038
4.077.248
695
U-4-10-ii
9.552.155
9.838.719
10.029.762
10.220.805
696
U-4-10-iii
13.934.513
14.352.549
14.631.239
14.909.929
697
U-4-11-i
1.929.531
1.987.417
2.026.008
2.064.598
698
U-4-11-ii
2.894.297
2.981.126
3.039.012
3.096.897
699
U-4-11-iii
4.383.597
4.515.105
4.602.777
4.690.449
700
U-4-12-i
1.929.531
1.987.417
2.026.008
2.064.598
701
U-4-12-ii
2.463.379
2.537.280
2.586.548
2.635.815
702
U-4-12-iii
3.916.660
4.034.160
4.112.493
4.190.827
703
U-4-13-i
1.929.531
1.987.417
2.026.008
2.064.598
704
U-4-13-ii
2.203.772
2.269.885
2.313.960
2.358.036
705
U-4-13-iii
2.740.264
2.822.472
2.877.277
2.932.082
706
U-4-14-i
2.411.914
2.484.271
2.532.510
2.580.748
707
U-4-14-ii
2.894.297
2.981.126
3.039.012
3.096.897
708
U-4-14-iii
4.848.449
4.993.903
5.090.872
5.187.841
709
U-4-15-i
1.929.531
1.987.417
2.026.008
2.064.598
710
U-4-15-ii
2.411.914
2.484.271
2.532.510
2.580.748
711
U-4-15-iii
3.377.334
3.478.654
3.546.201
3.613.747
712
V-1-10-i
5.640.659
5.809.879
5.922.692
6.035.505
713
V-1-10-ii
6.498.117
6.693.061
6.823.023
6.952.985
714
V-1-10-iii
12.346.422
12.716.815
12.963.744
13.210.672
715
V-1-11-i
6.498.117
6.693.061
6.823.023
6.952.985
716
V-1-11-ii
7.252.008
7.469.568
7.614.608
7.759.648
717
V-1-11-iii
10.739.113
11.061.286
11.276.069
11.490.851
3.843.374
3.958.675
4.035.543
4.112.410
14.410.510
14.842.825
15.131.035
15.419.245
16.206.508
16.692.703
17.016.833
17.340.963
5.825.309
6.000.068
6.116.574
6.233.081
718
V-1-12-i
719
V-1-12-ii
720
V-1-12-iii
721
V-1-13-i


DAN TELINGA RINGAN
DAN TELINGA SEDANG
DAN TELINGA BERAT


KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

- 371 No
Kode
INA-CBG
722
V-1-13-ii
723
V-1-13-iii
724
V-1-14-i
725
V-1-14-ii
726
V-1-14-iii
727
V-1-15-i
728
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
11.069.758
11.401.851
11.623.246
11.844.642
15.595.481
16.063.345
16.375.255
16.687.165
7.022.477
7.233.152
7.373.601
7.514.051
10.213.592
10.520.000
10.724.271
10.928.543
13.883.892
14.300.409
14.578.087
14.855.765
3.310.707
3.410.028
3.476.243
3.542.457
V-1-15-ii
6.084.443
6.266.976
6.388.665
6.510.354
729
V-1-15-iii
10.123.224
10.426.921
10.629.385
10.831.850
730
V-4-10-i
5.331.074
5.491.007
5.597.628
5.704.249
731
V-4-10-ii
6.885.719
7.092.291
7.230.005
7.367.720
732
V-4-10-iii
13.159.818
13.554.613
13.817.809
14.081.005
733
V-4-11-i
2.711.051
2.792.382
2.846.603
2.900.825
734
V-4-11-ii
3.961.279
4.080.117
4.159.343
4.238.568
735
V-4-11-iii
6.535.847
6.731.923
6.862.640
6.993.357
736
W-1-01-i
7.971.817
8.210.972
8.370.408
8.529.845
737
W-1-01-ii
9.601.676
9.889.726
10.081.760
10.273.793
738
W-1-01-iii
21.208.195
21.844.440
22.268.604
22.692.768
739
W-1-10-i
2.220.142
2.286.746
2.331.149
2.375.551
740
W-1-10-ii
4.143.148
4.267.443
4.350.306
4.433.169
741
W-1-10-iii
6.776.876
6.980.183
7.115.720
7.251.258
742
W-1-11-i
2.305.989
2.375.168
2.421.288
2.467.408
743
W-1-11-ii
4.447.391
4.580.813
4.669.761
4.758.709
744
W-1-11-iii
7.797.740
8.031.673
8.187.627
8.343.582
745
W-1-12-i
2.095.337
2.158.197
2.200.104
2.242.011
746
W-1-12-ii
2.382.358
2.453.829
2.501.476
2.549.124
747
W-1-12-iii
3.659.603
3.769.391
3.842.583
3.915.775
748
W-1-13-i
2.277.301
2.345.620
2.391.166
2.436.712
749
W-1-13-ii
2.472.493
2.546.668
2.596.118
2.645.567
750
W-1-13-iii
3.321.014
3.420.645
3.487.065
3.553.485
751
W-1-20-i
6.795.294
6.999.153
7.135.059
7.270.965
752
W-1-20-ii
9.558.601
9.845.359
10.036.531
10.227.703
753
W-1-20-iii
11.696.611
12.047.509
12.281.441
12.515.373

NON KOMPLEK (BERAT)

RINGAN
SEDANG
BERAT

SERVIK RINGAN
SERVIK SEDANG
SERVIK BERAT
ENDOSKOP RINGAN
ENDOSKOP SEDANG
ENDOSKOP BERAT
- 372 No
Kode
INA-CBG
754
W-1-30-i
755
W-1-30-ii
756
W-1-30-iii
757
W-4-10-i
758
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.709.549
3.820.836
3.895.027
3.969.218
5.916.923
6.094.431
6.212.769
6.331.107
15.734.554
16.206.591
16.521.282
16.835.973
2.766.394
2.849.386
2.904.714
2.960.042
W-4-10-ii
3.739.092
3.851.265
3.926.046
4.000.828
759
W-4-10-iii
7.718.125
7.949.668
8.104.031
8.258.393
760
W-4-11-i
2.411.914
2.484.271
2.532.510
2.580.748
761
W-4-11-ii
3.859.062
3.974.834
4.052.015
4.129.197
762
W-4-11-iii
4.689.904
4.830.602
4.924.400
5.018.198
1.929.531
1.987.417
2.026.008
2.064.598
2.684.982
2.765.531
2.819.231
2.872.931
3.239.312
3.336.491
3.401.277
3.466.064

RINGAN
SEDANG
BERAT

763
W-4-12-i
764
W-4-12-ii
765
W-4-12-iii
766
W-4-13-i
ABORTUS RINGAN
1.058.178
1.089.923
1.111.087
1.132.250
767
W-4-13-ii
ABORTUS SEDANG
1.447.148
1.490.563
1.519.506
1.548.449
768
W-4-13-iii
ABORTUS BERAT
1.929.531
1.987.417
2.026.008
2.064.598
769
W-4-14-i
1.447.148
1.490.563
1.519.506
1.548.449
770
W-4-14-ii
1.929.531
1.987.417
2.026.008
2.064.598
771
W-4-14-iii
2.342.043
2.412.304
2.459.145
2.505.986
772
W-4-15-i
1.321.555
1.361.201
1.387.632
1.414.064
773
W-4-15-ii
1.469.821
1.513.915
1.543.312
1.572.708
774
W-4-15-iii
1.967.761
2.026.794
2.066.149
2.105.504
775
W-4-16-i
1.447.148
1.490.563
1.519.506
1.548.449
776
W-4-16-ii
2.100.620
2.163.638
2.205.651
2.247.663
777
W-4-16-iii
2.677.194
2.757.510
2.811.054
2.864.598
778
W-4-17-i
1.294.410
1.333.243
1.359.131
1.385.019
779
W-4-17-ii
1.929.531
1.987.417
2.026.008
2.064.598
780
W-4-17-iii
3.650.289
3.759.798
3.832.804
3.905.809
781
Z-4-10-i
REHABILITASI RINGAN
3.310.847
3.410.172
3.476.389
3.542.606
782
Z-4-10-ii
REHABILITASI SEDANG
4.394.671
4.526.512
4.614.405
4.702.298
783
Z-4-10-iii
REHABILITASI BERAT
6.243.050
6.430.341
6.555.202
6.680.063
784
Z-4-11-i
3.164.938
3.259.887
3.323.185
3.386.484
785
Z-4-11-ii
3.809.886
3.924.183
4.000.381
4.076.578
786
Z-4-11-iii
5.956.233
6.134.920
6.254.045
6.373.169
1.447.148
1.490.563
1.519.506
1.548.449
3.229.017
3.325.887
3.390.468
3.455.048
4.103.569
4.226.676
4.308.748
4.390.819
787
Z-4-12-i
788
Z-4-12-ii
789
Z-4-12-iii

- 373 b. RawatJalan
No
Kode
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
800.166
824.171
840.174
856.178
1.037.940
1.069.079
1.089.837
1.110.596
1.930.187
1.988.093
2.026.696
2.065.300
1.595.112
1.642.966
1.674.868
1.706.770
1.332.579
1.372.556
1.399.208
1.425.859
467.208
481.224
490.568
499.913
1.041.813
1.073.067
1.093.903
1.114.739

214.058
220.480
224.761
229.042
C-3-10-0
583.921
601.438
613.117
624.795
10
C-3-11-0

KANDUNG KEMIH
923.492
951.197
969.667
988.137
11
C-3-12-0
209.354
215.634
219.822
224.009
203.297
209.396
213.462
217.528
1.730.670
1.782.590
1.817.203
1.851.817
1.586.228
1.633.815
1.665.539
1.697.264

LAPAROSKOPI
PROSEDUR LAIN-LAIN PADA HEPATOBILIARI
& PANKREAS
LAPAROSKOPI
PROSEDUR PADA PERKUTAN HATI &
SALURAN EMPEDU

OVARIUM
GASTROINTESTINAL
GINJAL ATAU PROSTAT
12
C-3-13-0
13
C-3-14-0
14
C-3-15-0
15
C-3-16-0
359.718
370.510
377.704
384.899
16
C-3-17-0

LEHER
238.627
245.785
250.558
255.330
17
C-3-18-0
105.797
108.971
111.087
113.202
18
C-3-19-0

MYELOMA ATAU TESTIS
149.618
154.107
157.099
160.091
19
C-3-20-0
2.979.648
3.069.038
3.128.631
3.188.224
20
C-3-21-0
170.741
175.863
179.278
182.693
21
C-3-22-0
749.644
772.133
787.126
802.119
22
C-3-23-0
121.426
125.069
127.497
129.926
23
D-2-10-0

TULANG
1.028.737
1.059.599
1.080.174
1.100.749
24
D-2-11-0
PROSEDUR LIMPA
1.288.155
1.326.799
1.352.563
1.378.326
25
D-2-21-0
1.080.397
1.112.809
1.134.417
1.156.025
26
D-2-22-0
237.115
244.228
248.970
253.713
27
D-3-10-0
171.748
176.900
180.335
183.770
28
D-3-11-0
445.907
459.284
468.203
477.121
29
E-2-10-0
264.509
272.444
277.734
283.024
30
E-2-21-0
191.760
197.513
201.348
205.183
31
E-2-22-0
191.760
197.513
201.348
205.183

TYMUS
TYMUS
TULANG
PEMBENTUK DARAH
PROSEDUR BESAR PADA KELENJAR TIROID
DAN PARATIROID
THYROGLOSSAL
- 374 No
Kode
INA-CBG
32
E-3-10-0
33
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

ENDOKRIN
223.004
229.694
234.155
238.615
F-3-10-0
TERAPI SHOCK
311.084
320.416
326.638
332.860
34
F-5-10-0
381.178
392.614
400.237
407.861
35
F-5-11-0
TERAPI KELOMPOK
251.352
258.893
263.920
268.947
36
F-5-12-0
321.648
331.297
337.730
344.163
37
F-5-13-0
272.414
280.587
286.035
291.483
38
F-5-14-0
182.753
188.236
191.891
195.546
39
F-5-15-0
171.446
176.590
180.019
183.447
40
F-5-16-0
178.578
183.935
187.507
191.078
41
G-2-10-0
150.376
154.887
157.895
160.903
42
G-2-11-0
1.303.524
1.342.630
1.368.700
1.394.771
43
G-2-12-0

EKSTRAKRANIAL
1.889.128
1.945.801
1.983.584
2.021.366
44
G-2-13-0
853.963
879.581
896.661
913.740
45
G-2-21-0
845.246
870.603
887.508
904.413
46
G-2-22-0
767.132
790.146
805.489
820.832
47
G-2-31-0
2.332.479
2.402.453
2.449.103
2.495.752
48
G-2-32-0
1.195.627
1.231.495
1.255.408
1.279.321
49
G-3-10-0
474.552
488.789
498.280
507.771
50
G-3-11-0
342.993
353.282
360.142
367.002
51
G-3-12-0
561.999
578.859
590.099
601.339
52
G-3-13-0
562.063
578.925
590.167
601.408
53
H-2-21-0
737.625
759.754
774.506
789.259
54
H-2-22-0
191.760
197.513
201.348
205.183
55
H-2-23-0
191.760
197.513
201.348
205.183
1.221.814
1.258.469
1.282.905
1.307.341
127.162
130.977
133.520
136.064
191.760
197.513
201.348
205.183
548.136
564.580
575.542
586.505
180.623
186.042
189.654
193.267
974.961
1.004.210
1.023.710
1.043.209
1.037.889
1.069.026
1.089.784
1.110.542
361.110
371.943
379.165
386.387

AKUT
MENTAL
PROSEDUR KRANIOTOMI

MATA
MATA
MATA
MATA
MATA
56
H-2-31-0
57
H-2-32-0
58
H-2-33-0
59
H-2-34-0
60
H-2-35-0
61
H-2-36-0
62
H-2-37-0

63
H-3-10-0
- 375 No
Kode
INA-CBG
64
H-3-11-0
65
H-3-12-0
66
H-3-13-0
67
I-2-11-0
68
I-2-12-0
69
I-2-13-0
70
I-2-14-0
71
I-2-15-0
72
I-2-16-0
73
I-2-17-0
74
I-2-21-0
75
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
189.904
195.601
199.399
203.197
198.269
204.217
208.183
212.148
192.507
198.283
202.133
205.983
2.220.020
2.286.620
2.331.021
2.375.421
1.560.916
1.607.744
1.638.962
1.670.180
1.983.831
2.043.345
2.083.022
2.122.699
3.510.958
3.616.286
3.686.505
3.756.725
211.142
217.476
221.699
225.922
2.217.614
2.284.142
2.328.495
2.372.847
731.084
753.016
767.638
782.259
1.711.683
1.763.033
1.797.267
1.831.500
I-2-22-0
1.611.849
1.660.204
1.692.441
1.724.678
76
I-2-23-0
329.860
339.756
346.353
352.950
77
I-2-31-0
2.565.433
2.642.396
2.693.705
2.745.014
78
I-2-32-0
3.354.681
3.455.321
3.522.415
3.589.508
79
I-2-41-0
2.249.355
2.316.835
2.361.822
2.406.809
80
I-2-42-0

LAIN
2.615.247
2.693.704
2.746.009
2.798.314
81
I-3-10-0
PROSEDUR RESUSITASI
331.982
341.942
348.581
355.221
82
I-3-11-0
175.220
180.476
183.981
187.485
83
I-3-12-0
1.018.310
1.048.859
1.069.225
1.089.591
84
I-3-13-0
334.452
344.486
351.175
357.864
85
I-3-14-0
214.373
220.804
225.091
229.379
86
I-3-15-0
189.904
195.601
199.399
203.197
87
J-2-10-0
1.175.761
1.211.034
1.234.549
1.258.065
88
J-2-21-0
189.532
195.218
199.009
202.800
89
J-2-22-0
955.125
983.779
1.002.882
1.021.984
90
J-2-31-0
PROSEDUR
1.238.883
1.276.050
1.300.827
1.325.605
91
J-2-32-0
921.935
949.593
968.031
986.470
92
J-3-10-0
191.760
197.513
201.348
205.183
93
J-3-11-0

PADA DADA
541.879
558.136
568.973
579.811
94
J-3-12-0
209.354
215.634
219.822
224.009
95
J-3-13-0
308.117
317.360
323.522
329.685

MATA
TORASIK
ABDOMEN
PENGGANTIAN ALAT
DARAH VENA

PACU JANTUNG

KARDIOVASKULAR
PERNAFASAN
PENDEK
- 376 No
Kode
INA-CBG
96
J-3-14-0
97
J-3-15-0
98
J-3-16-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
327.099
336.912
343.454
349.996
286.840
295.445
301.182
306.919
327.099
336.912
343.454
349.996
191.760
197.513
201.348
205.183
551.950
568.509
579.548
590.587
1.178.639
1.213.999
1.237.571
1.261.144
904.758
931.900
949.996
968.091
1.472.542
1.516.718
1.546.169
1.575.620
191.760
197.513
201.348
205.183
191.760
197.513
201.348
205.183
2.464.571
2.538.508
2.587.799
2.637.091
828.710
853.571
870.145
886.719
191.760
197.513
201.348
205.183

PERNAFASAN
KECIL
99
J-3-17-0
100
K-2-10-0
101
K-2-11-0
102
K-2-12-0

103
K-2-13-0
104
K-2-14-0
105
K-2-21-0
106
K-2-22-0
107
K-2-31-0
108
K-2-32-0
109
K-2-41-0
912.841
940.226
958.483
976.740
110
K-2-42-0

260.810
268.634
273.850
279.067
111
K-2-51-0
604.904
623.051
635.149
647.247
112
K-2-52-0
329.860
339.756
346.353
352.950
113
K-2-53-0
191.760
197.513
201.348
205.183
114
K-3-10-0

GASTROINTESTINAL
364.906
375.853
383.151
390.450
115
K-3-11-0
219.380
225.961
230.349
234.736
116
K-3-12-0
222.479
229.153
233.603
238.052
117
K-3-13-0
191.760
197.513
201.348
205.183
118
K-3-14-0
513.921
529.338
539.617
549.895
119
K-3-15-0
248.179
255.625
260.588
265.552
120
K-3-16-0
328.854
338.719
345.296
351.873
121
L-2-21-0
1.130.610
1.164.529
1.187.141
1.209.753
122
L-2-22-0
724.713
746.455
760.949
775.443
123
L-2-31-0
327.099
336.912
343.454
349.996
124
L-2-32-0
329.860
339.756
346.353
352.950
125
L-2-41-0
987.727
1.017.359
1.037.113
1.056.868
126
L-2-42-0

221.531
228.177
232.608
237.038
127
L-2-51-0
1.478.782
1.523.145
1.552.721
1.582.297
128
L-2-52-0

1.131.317
1.165.256
1.187.883
1.210.509

FEMORALIS
USUS BESAR
ATAS
PROSEDUR SEDANG PADA

GASTROINTESTINAL
LUKA BAKAR
LUKA BAKAR
PROSEDUR BESAR PEMINDAHAN KULIT
TANPA LUKA BAKAR
PROSEDUR KECIL PEMINDAHAN KULIT
TANPA LUKA BAKAR
- 377 No
Kode
INA-CBG
129
L-2-53-0
130
L-3-10-0
131
L-3-11-0
132
L-3-12-0
133
M-2-10-0
134
M-2-21-0
135
M-2-22-0
136
M-2-31-0
PROSEDUR BUNION
137
M-2-32-0
138
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
191.760
197.513
201.348
205.183
260.810
268.634
273.850
279.067
253.264
260.862
265.928
270.993
192.885
198.672
202.529
206.387
1.512.902
1.558.289
1.588.547
1.618.805
2.496.608
2.571.506
2.621.438
2.671.370
607.813
626.048
638.204
650.360
1.516.438
1.561.932
1.592.260
1.622.589
480.579
494.996
504.608
514.219
M-2-41-0

TULANG
480.579
494.996
504.608
514.219
139
M-2-42-0
165.621
170.589
173.902
177.214
140
M-2-51-0
353.344
363.945
371.012
378.078
141
M-2-52-0
353.344
363.945
371.012
378.078
142
M-2-61-0
PROSEDUR ARTROSKOPI
1.731.926
1.783.883
1.818.522
1.853.160
143
M-2-62-0
353.344
363.945
371.012
378.078
144
M-2-63-0
1.741.295
1.793.533
1.828.359
1.863.185
145
M-2-64-0
2.374.766
2.446.009
2.493.504
2.541.000
146
M-2-65-0
353.344
363.945
371.012
378.078
147
M-2-71-0
1.753.202
1.805.798
1.840.862
1.875.926
148
M-2-72-0
1.691.914
1.742.672
1.776.510
1.810.348
149
M-2-81-0
2.523.004
2.598.694
2.649.155
2.699.615
150
M-2-82-0
1.832.801
1.887.785
1.924.441
1.961.097
151
M-2-83-0
353.344
363.945
371.012
378.078
152
M-2-84-0
353.344
363.945
371.012
378.078
153
M-3-10-0
1.008.513
1.038.768
1.058.939
1.079.109
154
M-3-11-0
559.159
575.934
587.117
598.300
155
M-3-12-0
1.264.495
1.302.430
1.327.720
1.353.010
156
M-3-13-0
412.260
424.627
432.873
441.118
157
M-3-14-0

TERTUTUP
704.621
725.760
739.852
753.945
158
M-3-15-0
310.429
319.742
325.950
332.159
159
M-3-16-0

353.344
363.945
371.012
378.078

PAYUDARA

DAN WAJAH
PAHA
PAHA

TULANG
WAJAH
WAJAH
BAWAH
BAWAH
PROSEDUR BESAR PADA LENGAN, SIKU &
BAHU
PROSEDUR KECIL PADA LENGAN, SIKU &
BAHU
PERGELANGAN TANGAN
PERGELANGAN TANGAN
MUSKULOSKELETAL
SKELETAL
- 378 No
Kode
INA-CBG
160
M-3-17-0
161
N-2-11-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
385.764
397.337
405.052
412.767
2.533.336
2.609.336
2.660.002
2.710.669
1.465.510
1.509.475
1.538.785
1.568.095
1.457.785
1.501.518
1.530.674
1.559.830
162
N-2-12-0
163
N-2-21-0
164
N-2-22-0
329.860
339.756
346.353
352.950
165
N-2-23-0
PROSEDUR SEDANG PADA GINJAL DAN

URETER
329.860
339.756
346.353
352.950
166
N-2-24-0
1.065.997
1.097.977
1.119.297
1.140.617
167
N-2-31-0
897.397
924.319
942.267
960.214
168
N-2-32-0
329.860
339.756
346.353
352.950
169
N-2-41-0
329.860
339.756
346.353
352.950
170
N-2-42-0
557.857
574.592
585.749
596.907
171
N-3-10-0
329.860
339.756
346.353
352.950
172
N-3-11-0
382.190
393.656
401.300
408.943
173
N-3-12-0
295.335
304.195
310.102
316.008
174
N-3-13-0
329.860
339.756
346.353
352.950
175
N-3-14-0
283.827
292.341
298.018
303.695
176
N-3-15-0
727.803
749.637
764.193
778.749
177
O-7-10-0
121.512
125.157
127.587
130.018
178
O-7-11-0
669.197
689.273
702.657
716.041
179
O-7-12-0
243.677
250.988
255.861
260.735
180
O-7-13-0
135.425
139.488
142.196
144.905
181
P-9-10-0
180.623
186.042
189.654
193.267
182
P-9-11-0
180.623
186.042
189.654
193.267
183
P-9-12-0
180.623
186.042
189.654
193.267
184
P-9-13-0
180.623
186.042
189.654
193.267
185
P-9-14-0
180.623
186.042
189.654
193.267
186
P-9-15-0
115.133
118.587
120.890
123.192
187
P-9-16-0
180.623
186.042
189.654
193.267
188
P-9-17-0
179.846
185.242
188.839
192.436
189
Q-5-10-0
235.410
242.472
247.180
251.888
190
Q-5-11-0
176.433
181.726
185.255
188.783
191
Q-5-12-0
GIGI
155.503
160.169
163.279
166.389

DAN URETHRA
PROSEDUR KECIL PADA KANDUNG KEMIH
DAN URETHRA
TRANSURETHRA
TRANSURETHRA
SALURAN KEMIH
PROSEDUR BESAR ENDOSKOPI PADA
SALURAN KEMIH
KEMIH
PROSEDUR DIALISIS
CAESAR
VAGINAL/JALAN LAHIR
NEONATAL, MENINGGAL DAN DITRANSFER
KE FASILITAS PERAWATAN PASIEN AKUT LAIN

ASPIRASI
- 379 No
Kode
INA-CBG
192
Q-5-13-0
193
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
MEDICAL CHECK-UP
118.176
121.721
124.085
126.448
Q-5-14-0
130.032
133.933
136.534
139.134
194
Q-5-15-0
89.423
92.106
93.894
95.683
195
Q-5-16-0
VAKSINASI
101.069
104.101
106.122
108.143
196
Q-5-17-0
PASANG INFUS
87.422
90.044
91.793
93.541
197
Q-5-18-0
164.555
169.492
172.783
176.074
198
Q-5-19-0
KONTAK PELAYANAN KESEHATAN LAINLAIN
183.963
189.481
193.161
196.840
199
Q-5-20-0
ABORSI MENGANCAM
123.304
127.003
129.469
131.935
200
Q-5-21-0
ABORSI
121.625
125.273
127.706
130.138
201
Q-5-22-0
130.032
133.933
136.534
139.134
202
Q-5-23-0
159.194
163.969
167.153
170.337
203
Q-5-24-0
108.727
111.989
114.163
116.338
204
Q-5-25-0
169.557
174.644
178.035
181.426
205
Q-5-26-0
BRONKIAL AKUT
239.997
247.197
251.997
256.797
206
Q-5-27-0
170.793
175.917
179.333
182.749
207
Q-5-28-0
138.594
142.752
145.524
148.296
208
Q-5-29-0

JANTUNG LAIN-LAIN
392.384
404.155
412.003
419.850
209
Q-5-30-0
454.730
468.372
477.467
486.561
210
Q-5-31-0
FRAKTUR
162.230
167.096
170.341
173.586
211
Q-5-32-0
SALURAN KEMIH AKUT
187.898
193.535
197.293
201.051
212
Q-5-33-0
HEMATOLOGI AKUT
196.729
202.631
206.565
210.500
213
Q-5-34-0
INFEKSI VIRUS HIV
279.467
287.851
293.441
299.030
214
Q-5-35-0
INFEKSI AKUT
316.908
326.416
332.754
339.092
215
Q-5-36-0
369.060
380.132
387.513
394.894
216
Q-5-37-0

SHOCK
188.240
193.887
197.652
201.416
217
Q-5-38-0
PARU AKUT
251.024
258.554
263.575
268.595
218
Q-5-39-0
160.637
165.456
168.668
171.881
219
Q-5-40-0
157.610
162.339
165.491
168.643
220
Q-5-41-0
218.189
224.735
229.098
233.462
221
Q-5-42-0
171.069
176.201
179.622
183.044
222
Q-5-43-0
246.349
253.739
258.666
263.593
223
Q-5-44-0
201.055
207.087
211.108
215.129
224
T-2-10-0

TERAPI DETOKSIKASI
104.284
107.412
109.498
111.584
225
U-2-10-0
1.391.785
1.433.539
1.461.375
1.489.210
- 380 No
Kode
INA-CBG
Deskripsi (INA-CBG)
226
U-2-11-0

LEHER
227
U-2-12-0
228
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.654.292
1.703.920
1.737.006
1.770.092
182.015
187.476
191.116
194.756
U-2-13-0
238.627
245.785
250.558
255.330
229
U-2-14-0
443.260
456.558
465.423
474.288
230
U-2-15-0
251.851
259.406
264.443
269.480
231
U-2-21-0
293.367
302.168
308.035
313.902
232
U-2-22-0
566.808
583.812
595.148
606.484
233
U-2-23-0
742.701
764.982
779.836
794.690
234
U-2-24-0
625.936
644.714
657.233
669.751
235
U-2-25-0
238.627
245.785
250.558
255.330
236
U-2-31-0
191.760
197.513
201.348
205.183
237
U-2-32-0
238.627
245.785
250.558
255.330
228.140
234.984
239.546
244.109
242.213
249.479
254.324
259.168
107.106
110.319
112.462
114.604
235.428
242.491
247.199
251.908
216.310
222.799
227.125
231.451
188.641
194.301
198.073
201.846
212.753
219.136
223.391
227.646
2.075.654
2.137.923
2.179.436
2.220.949
234.081
241.103
245.785
250.467
746.986
769.395
784.335
799.275
329.860
339.756
346.353
352.950
329.860
339.756
346.353
352.950

(RHINOPLASTY)
PROSEDUR SEDANG LAIN-LAIN PADA

TENGGOROKAN
RONGGA HIDUNG
TENGGOROKAN
238
U-3-10-0
239
U-3-11-0
240
U-3-12-0
241
U-3-13-0
242
U-3-14-0
243
U-3-15-0
244
U-3-16-0
PROSEDUR PADA GIGI
245
V-2-10-0

PROSTAT
246
V-2-11-0
PROSEDUR PADA PENIS

SKROTUM
SKROTUM
TRANSURETHRAL
247
V-2-12-0
248
V-2-13-0
249
V-2-14-0
250
V-2-15-0
SIRKUMSISI/SUNAT
180.623
186.042
189.654
193.267
251
V-3-10-0
376.702
388.003
395.537
403.071
252
V-3-11-0
796.919
820.827
836.765
852.704
253
V-3-12-0
460.083
473.885
483.087
492.288
254
W-2-10-0
168.470
173.524
176.893
180.262
255
W-2-11-0
430.545
443.462
452.073
460.684
256
W-2-12-0
796.919
820.827
836.765
852.704

PROSEDUR ABORSI
RAHIM & LEHER RAHIM
TERHALANG/TERGANGGU
- 381 No
Kode
INA-CBG
257
W-2-13-0
258
W-2-21-0
259
W-2-22-0
260
W-2-23-0
261
W-2-31-0
262
W-2-32-0
263
W-2-33-0
264
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
127.812
131.646
134.202
136.758
2.951.946
3.040.505
3.099.544
3.158.583
310.429
319.742
325.950
332.159
562.191
579.057
590.301
601.545
1.845.502
1.900.867
1.937.777
1.974.688
1.294.335
1.333.165
1.359.051
1.384.938
550.109
566.613
577.615
588.617
W-2-34-0
187.102
192.715
196.457
200.199
265
W-3-10-0
454.730
468.372
477.466
486.561
266
W-3-11-0
363.498
374.403
381.673
388.943
267
W-3-12-0
168.470
173.524
176.893
180.262
268
Z-3-10-0
1.907.300
1.964.519
2.002.665
2.040.811
269
Z-3-11-0

EMPEDU
1.457.785
1.501.518
1.530.674
1.559.830
270
Z-3-12-0
243.415
250.717
255.586
260.454
271
Z-3-13-0

LAIN-LAIN
1.485.384
1.529.945
1.559.653
1.589.361
272
Z-3-14-0
DIAGNOSTIK TIDUR
293.706
302.518
308.392
314.266
273
Z-3-15-0
191.760
197.513
201.348
205.183
274
Z-3-16-0

(MRI)
615.491
633.956
646.265
658.575
275
Z-3-17-0
PENGOBATAN NUKLIR
258.396
266.148
271.316
276.484
276
Z-3-18-0
CT-SCAN KEPALA
248.960
256.429
261.408
266.387
277
Z-3-19-0
CT SCAN LAIN-LAIN
259.119
266.892
272.075
277.257
278
Z-3-20-0
176.233
181.520
185.045
188.569
279
Z-3-21-0
168.470
173.524
176.893
180.262
280
Z-3-22-0
189.934
195.632
199.431
203.230
281
Z-3-23-0
197.833
203.768
207.725
211.681
282
Z-3-24-0
388.703
400.364
408.138
415.912
283
Z-3-25-0
173.128
178.321
181.784
185.247
284
Z-3-26-0
195.668
201.538
205.452
209.365
285
Z-3-27-0
PERAWATAN LUKA
186.810
192.415
196.151
199.887
286
Z-3-28-0
IMAGING PAYUDARA
191.760
197.513
201.348
205.183
287
Z-3-29-0
IMAGING LAIN-LAIN
552.686
569.267
580.321
591.375
288
Z-3-30-0
FOTOTERAPI
93.273
96.071
97.937
99.802

TERHALANG/TERGANGGU
PANGGUL TERBUKA
PANGGUL TERBUKA
JALAN LAHIR
- 382 5. RUMAH SAKIT PARUKELAS B PENDIDIKAN

a. RawatInap
No
Kode
INA-CBG
A-4-10-i
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
SEPTIKEMIA RINGAN
2.736.833
2.818.938
2.873.675
2.928.411
A-4-10-ii
SEPTIKEMIA SEDANG
3.132.938
3.226.926
3.289.585
3.352.244
A-4-10-iii
SEPTIKEMIA BERAT
4.911.856
5.059.212
5.157.449
5.255.686
A-4-11-i
4.918.728
5.066.290
5.164.664
5.263.039
A-4-11-ii
7.598.866
7.826.832
7.978.809
8.130.787
A-4-11-iii
12.430.084
12.802.987
13.051.589
13.300.190
A-4-12-i
DEMAM RINGAN
1.929.531
1.987.417
2.026.008
2.064.598
A-4-12-ii
DEMAM SEDANG
2.767.495
2.850.520
2.905.870
2.961.219
A-4-12-iii
DEMAM BERAT
3.167.195
3.262.211
3.325.555
3.388.898
10
A-4-13-i
2.411.914
2.484.271
2.532.510
2.580.748
11
A-4-13-ii
2.894.297
2.981.126
3.039.012
3.096.897
12
A-4-13-iii
3.517.676
3.623.206
3.693.559
3.763.913
1.929.531
1.987.417
2.026.008
2.064.598
3.064.499
3.156.434
3.217.723
3.279.013
3.489.611
3.594.300
3.664.092
3.733.884

RINGAN
SEDANG

LAIN-LAIN RINGAN
LAIN-LAIN SEDANG
LAIN-LAIN BERAT
13
A-4-14-i
14
A-4-14-ii
15
A-4-14-iii
16
A-4-15-i
INFEKSI HIV RINGAN
2.894.297
2.981.126
3.039.012
3.096.897
17
A-4-15-ii
INFEKSI HIV SEDANG
4.341.445
4.471.688
4.558.517
4.645.346
18
A-4-15-iii
INFEKSI HIV BERAT
6.037.927
6.219.065
6.339.824
6.460.582
19
B-1-01-i
32.087.791
33.050.425
33.692.181
34.333.937
20
B-1-01-ii
35.401.413
36.463.455
37.171.483
37.879.512
21
B-1-01-iii
62.101.363
63.964.404
65.206.431
66.448.458
22
B-1-10-i
4.160.073
4.284.875
4.368.077
4.451.278
23
B-1-10-ii
10.601.870
10.919.927
11.131.964
11.344.001
24
B-1-10-iii
18.453.662
19.007.272
19.376.345
19.745.418
25
B-1-11-i
2.843.954
2.929.272
2.986.151
3.043.030
26
B-1-11-ii
7.138.592
7.352.750
7.495.521
7.638.293
27
B-1-11-iii
8.950.023
9.218.523
9.397.524
9.576.524
28
B-1-12-i
6.066.256
6.248.243
6.369.568
6.490.893
29
B-1-12-ii
13.001.469
13.391.514
13.651.543
13.911.572
30
B-1-12-iii
15.823.278
16.297.977
16.614.442
16.930.908

(RINGAN)
(SEDANG)
(BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT
- 383 No
Kode
INA-CBG
31
B-1-13-i
32
B-1-13-ii
33
B-1-13-iii
34
B-1-14-i
35
B-1-14-ii
36
B-1-14-iii
37
B-4-10-i
38
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.975.082
4.094.335
4.173.836
4.253.338
6.474.832
6.669.077
6.798.574
6.928.070
9.545.719
9.832.091
10.023.005
10.213.920
5.397.882
5.559.818
5.667.776
5.775.734
6.003.534
6.183.640
6.303.711
6.423.781
9.391.815
9.673.570
9.861.406
10.049.242
1.509.610
1.554.898
1.585.090
1.615.282
B-4-10-ii
2.411.914
2.484.271
2.532.510
2.580.748
39
B-4-10-iii
3.687.530
3.798.156
3.871.907
3.945.657
40
B-4-11-i
3.646.298
3.755.687
3.828.613
3.901.539
41
B-4-11-ii
5.543.284
5.709.582
5.820.448
5.931.313
42
B-4-11-iii
5.970.309
6.149.418
6.268.824
6.388.231
43
B-4-12-i
3.199.377
3.295.358
3.359.346
3.423.333
44
B-4-12-ii
4.535.929
4.672.007
4.762.725
4.853.444
45
B-4-12-iii
8.815.985
9.080.465
9.256.785
9.433.104
46
B-4-13-i
2.894.297
2.981.126
3.039.012
3.096.897
47
B-4-13-ii
4.516.709
4.652.210
4.742.544
4.832.878
48
B-4-13-iii
6.855.406
7.061.068
7.198.176
7.335.284
49
B-4-14-i
2.894.297
2.981.126
3.039.012
3.096.897
50
B-4-14-ii
3.376.680
3.477.980
3.545.513
3.613.047
51
B-4-14-iii
4.504.830
4.639.975
4.730.072
4.820.168
52
C-4-10-i
2.818.461
2.903.015
2.959.384
3.015.753
53
C-4-10-ii
5.475.974
5.640.253
5.749.772
5.859.292
54
C-4-10-iii
LEUKEMIA AKUT BERAT
9.165.273
9.440.231
9.623.537
9.806.842
55
C-4-11-i
2.894.297
2.981.126
3.039.012
3.096.897
56
C-4-11-ii
3.859.062
3.974.834
4.052.015
4.129.197
57
C-4-11-iii
6.560.858
6.757.683
6.888.901
7.020.118
58
C-4-12-i
RADIOTERAPI RINGAN
1.929.531
1.987.417
2.026.008
2.064.598
59
C-4-12-ii
RADIOTERAPI SEDANG
5.312.582
5.471.959
5.578.211
5.684.463
60
C-4-12-iii
RADIOTERAPI BERAT
10.785.606
11.109.174
11.324.886
11.540.598
61
C-4-13-i
KEMOTERAPI RINGAN
1.929.531
1.987.417
2.026.008
2.064.598
62
C-4-13-ii
KEMOTERAPI SEDANG
3.859.062
3.974.834
4.052.015
4.129.197
63
C-4-13-iii
KEMOTERAPI BERAT
5.049.298
5.200.776
5.301.762
5.402.748

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT

PANCREAS RINGAN
PANCREAS SEDANG
PANCREAS BERAT
(RINGAN)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT
- 384 No
Kode
INA-CBG
64
C-4-14-i
65
C-4-14-ii
66
C-4-14-iii
67
D-1-10-i
68
D-1-10-ii
69
D-1-10-iii
70
D-1-11-i
71
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.502.086
2.577.148
2.627.190
2.677.232
3.656.208
3.765.894
3.839.018
3.912.142
5.573.783
5.740.996
5.852.472
5.963.947
20.532.500
21.148.475
21.559.125
21.969.775
31.272.572
32.210.749
32.836.201
33.461.652
42.382.880
43.654.367
44.502.024
45.349.682
4.220.279
4.346.887
4.431.293
4.515.698
D-1-11-ii
11.007.262
11.337.480
11.557.625
11.777.770
72
D-1-11-iii
15.595.481
16.063.345
16.375.255
16.687.165
73
D-1-20-i
5.198.494
5.354.448
5.458.418
5.562.388
74
D-1-20-ii
11.696.611
12.047.509
12.281.441
12.515.373
75
D-1-20-iii
21.143.560
21.777.867
22.200.738
22.623.609
76
D-4-10-i
1.853.433
1.909.036
1.946.105
1.983.174
77
D-4-10-ii
3.742.430
3.854.703
3.929.552
4.004.400
78
D-4-10-iii
4.823.828
4.968.543
5.065.019
5.161.496
79
D-4-11-i
4.220.849
4.347.475
4.431.892
4.516.309
80
D-4-11-ii
7.543.794
7.770.107
7.920.983
8.071.859
81
D-4-11-iii
10.327.905
10.637.742
10.844.300
11.050.859
82
D-4-12-i
2.474.164
2.548.388
2.597.872
2.647.355
83
D-4-12-ii
3.431.908
3.534.865
3.603.503
3.672.142
84
D-4-12-iii
5.269.697
5.427.787
5.533.181
5.638.575
85
D-4-13-i
1.929.531
1.987.417
2.026.008
2.064.598
86
D-4-13-ii
2.894.297
2.981.126
3.039.012
3.096.897
87
D-4-13-iii
3.376.680
3.477.980
3.545.513
3.613.047
88
D-4-14-i
2.324.850
2.394.595
2.441.092
2.487.589
89
D-4-14-ii
5.427.955
5.590.794
5.699.353
5.807.912
90
D-4-14-iii
6.474.800
6.669.044
6.798.540
6.928.036
91
E-1-01-i
4.625.290
4.764.049
4.856.555
4.949.060
92
E-1-01-ii
6.058.690
6.240.451
6.361.625
6.482.798
93
E-1-01-iii
13.732.161
14.144.126
14.418.769
14.693.413
94
E-1-10-i
4.712.923
4.854.311
4.948.569
5.042.828
95
E-1-10-ii
5.720.382
5.891.994
6.006.401
6.120.809
96
E-1-10-iii
12.056.882
12.418.588
12.659.726
12.900.864

RINGAN
SEDANG
BERAT
TULANG RINGAN
TULANG SEDANG
TULANG BERAT


RINGAN
SEDANG
BERAT
- 385 No
Kode
INA-CBG
97
E-1-20-i
98
E-1-20-ii
99
E-1-20-iii
100
E-4-10-i
101
E-4-10-ii
102
E-4-10-iii
103
E-4-11-i
104
E-4-11-ii
105
E-4-11-iii
106
E-4-12-i
107
E-4-12-ii
108
E-4-12-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.457.662
5.621.392
5.730.546
5.839.699
7.309.657
7.528.947
7.675.140
7.821.333
16.196.134
16.682.018
17.005.941
17.329.864
2.411.914
2.484.271
2.532.510
2.580.748
3.430.249
3.533.157
3.601.762
3.670.367
6.556.854
6.753.560
6.884.697
7.015.834
2.057.867
2.119.603
2.160.760
2.201.918
3.893.131
4.009.925
4.087.788
4.165.650
6.419.952
6.612.551
6.740.950
6.869.349
2.458.864
2.532.629
2.581.807
2.630.984
4.271.509
4.399.655
4.485.085
4.570.515
6.975.048
7.184.299
7.323.800
7.463.301
2.593.620
2.671.428
2.723.301
2.775.173
4.453.263
4.586.861
4.675.926
4.764.992
7.705.270
7.936.428
8.090.534
8.244.639

RINGAN
SEDANG
BERAT

RINGAN
SEDANG
BERAT
109
E-4-13-i
110
E-4-13-ii
111
E-4-13-iii
112
F-4-10-i
SCHIZOFRENIA RINGAN
3.171.191
3.266.326
3.329.750
3.393.174
113
F-4-10-ii
SCHIZOFRENIA SEDANG
3.521.709
3.627.361
3.697.795
3.768.229
114
F-4-10-iii
SCHIZOFRENIA BERAT
5.213.968
5.370.387
5.474.667
5.578.946
115
F-4-11-i
2.923.070
3.010.762
3.069.223
3.127.685
116
F-4-11-ii
3.405.654
3.507.823
3.575.936
3.644.050
117
F-4-11-iii
DEPRESI MAYOR BERAT
4.367.293
4.498.312
4.585.657
4.673.003
1.447.148
1.490.563
1.519.506
1.548.449
2.066.323
2.128.312
2.169.639
2.210.965
4.482.540
4.617.016
4.706.667
4.796.318

IMPULSE RINGAN
IMPULSE SEDANG
IMPULSE BERAT
118
F-4-12-i
119
F-4-12-ii
120
F-4-12-iii
121
F-4-13-i
2.362.284
2.433.153
2.480.399
2.527.644
122
F-4-13-ii
3.128.272
3.222.120
3.284.685
3.347.251
123
F-4-13-iii
4.033.507
4.154.512
4.235.182
4.315.852
124
F-4-14-i
DEPRESI RINGAN
1.653.599
1.703.207
1.736.279
1.769.351
125
F-4-14-ii
DEPRESI SEDANG
2.121.076
2.184.709
2.227.130
2.269.552
126
F-4-14-iii
DEPRESI BERAT
2.854.003
2.939.623
2.996.703
3.053.783
127
F-4-15-i
1.966.035
2.025.016
2.064.337
2.103.658
128
F-4-15-ii
2.894.297
2.981.126
3.039.012
3.096.897
129
F-4-15-iii
3.811.966
3.926.325
4.002.565
4.078.804
- 386 No
Kode
INA-CBG
130
F-4-16-i
131
F-4-16-ii
132
F-4-16-iii
133
F-4-17-i
134
F-4-17-ii
135
F-4-17-iii
136
F-4-18-i
137
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.234.455
4.361.489
4.446.178
4.530.867
4.922.448
5.070.122
5.168.571
5.267.020
6.570.647
6.767.766
6.899.179
7.030.592
977.686
1.007.016
1.026.570
1.046.124
2.865.503
2.951.468
3.008.779
3.066.089
3.057.281
3.149.000
3.210.145
3.271.291
3.670.283
3.780.392
3.853.797
3.927.203
F-4-18-ii
4.038.348
4.159.499
4.240.265
4.321.032
138
F-4-18-iii
6.225.466
6.412.230
6.536.739
6.661.248
139
F-4-19-i
2.814.761
2.899.204
2.955.499
3.011.794
140
F-4-19-ii
3.604.374
3.712.505
3.784.592
3.856.680
141
F-4-19-iii
4.487.493
4.622.118
4.711.868
4.801.618
142
G-1-01-i
8.948.725
9.217.187
9.396.162
9.575.136
143
G-1-01-ii
15.146.796
15.601.200
15.904.136
16.207.072
144
G-1-01-iii
29.322.505
30.202.181
30.788.631
31.375.081
145
G-1-10-i
4.465.865
4.599.841
4.689.159
4.778.476
146
G-1-10-ii
6.304.692
6.493.832
6.619.926
6.746.020
147
G-1-10-iii
7.472.406
7.696.578
7.846.027
7.995.475
148
G-1-11-i
5.151.509
5.306.054
5.409.084
5.512.115
149
G-1-11-ii
10.579.012
10.896.382
11.107.962
11.319.543
150
G-1-11-iii
22.151.489
22.816.034
23.259.063
23.702.093
151
G-1-12-i
4.006.356
4.126.547
4.206.674
4.286.801
152
G-1-12-ii
9.172.154
9.447.318
9.630.761
9.814.204
153
G-1-12-iii
16.177.668
16.662.998
16.986.551
17.310.104
154
G-1-13-i
1.056.601
1.088.299
1.109.431
1.130.563
155
G-1-13-ii
2.837.914
2.923.052
2.979.810
3.036.568
156
G-1-13-iii
6.403.530
6.595.636
6.723.706
6.851.777
5.048.350
5.199.800
5.300.767
5.401.734
6.820.486
7.025.100
7.161.510
7.297.920
16.699.157
17.200.132
17.534.115
17.868.098

RINGAN
SEDANG
BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

RINGAN
SEDANG
BERAT
157
G-1-20-i
158
G-1-20-ii
159
G-1-20-iii
160
G-1-30-i
6.438.715
6.631.877
6.760.651
6.889.426
161
G-1-30-ii
16.805.665
17.309.835
17.645.948
17.982.061
162
G-1-30-iii
21.634.084
22.283.106
22.715.788
23.148.470
- 387 No
Kode
INA-CBG
163
G-4-10-i
164
G-4-10-ii
165
G-4-10-iii
166
G-4-11-i
167
G-4-11-ii
168
G-4-11-iii
169
G-4-12-i
170
G-4-12-ii
171
G-4-12-iii
172
G-4-13-i
173
G-4-13-ii
174
G-4-13-iii
175
G-4-14-i
176
G-4-14-ii
177
G-4-14-iii
178
G-4-15-i
179
G-4-15-ii
180
G-4-15-iii
181
G-4-16-i
182
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.894.297
2.981.126
3.039.012
3.096.897
3.376.680
3.477.980
3.545.513
3.613.047
5.158.630
5.313.389
5.416.561
5.519.734
4.775.382
4.918.644
5.014.151
5.109.659
5.539.443
5.705.627
5.816.415
5.927.204
8.118.150
8.361.694
8.524.057
8.686.420
3.571.566
3.678.713
3.750.144
3.821.575
4.500.173
4.635.178
4.725.181
4.815.185
6.535.965
6.732.044
6.862.763
6.993.483
1.987.195
2.046.811
2.086.555
2.126.299
3.376.680
3.477.980
3.545.513
3.613.047
3.991.715
4.111.466
4.191.300
4.271.135
3.634.284
3.743.312
3.815.998
3.888.684
5.979.623
6.159.012
6.278.604
6.398.197
7.486.624
7.711.223
7.860.956
8.010.688
3.719.795
3.831.389
3.905.785
3.980.181
4.494.815
4.629.659
4.719.555
4.809.452
5.554.365
5.720.996
5.832.083
5.943.170
2.411.914
2.484.271
2.532.510
2.580.748
G-4-16-ii
3.607.039
3.715.250
3.787.391
3.859.532
183
G-4-16-iii
6.546.132
6.742.516
6.873.438
7.004.361
184
G-4-17-i
3.446.846
3.550.251
3.619.188
3.688.125
185
G-4-17-ii
4.277.687
4.406.018
4.491.571
4.577.125
186
G-4-17-iii
7.169.439
7.384.522
7.527.911
7.671.299
187
G-4-18-i
2.894.297
2.981.126
3.039.012
3.096.897
188
G-4-18-ii
4.149.921
4.274.418
4.357.417
4.440.415
189
G-4-18-iii
4.396.418
4.528.311
4.616.239
4.704.167
190
G-4-19-i
2.411.914
2.484.271
2.532.510
2.580.748
191
G-4-19-ii
4.888.068
5.034.710
5.132.471
5.230.233

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
DEGENERATIF RINGAN
DEGENERATIF SEDANG
DEGENERATIF BERAT
RINGAN
SEDANG
BERAT
TRAUMATIK RINGAN
TRAUMATIK SEDANG
TRAUMATIK BERAT
DENGAN INFARK BERAT
TANPA INFARK RINGAN
TANPA INFARK SEDANG
TANPA INFARK BERAT

PERIFER RINGAN
PERIFER SEDANG
PERIFER BERAT
PERSARAFAN RINGAN
PERSARAFAN SEDANG
PERSARAFAN BERAT
RINGAN
SEDANG
- 388 No
Kode
INA-CBG
192
G-4-19-iii
193
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

7.291.446
7.510.189
7.656.018
7.801.847
G-4-20-i
1.688.340
1.738.990
1.772.757
1.806.524
194
G-4-20-ii
2.397.444
2.469.368
2.517.317
2.565.265
195
G-4-20-iii
4.088.204
4.210.850
4.292.614
4.374.378
196
G-4-21-i
1.956.400
2.015.092
2.054.220
2.093.348
197
G-4-21-ii
4.051.899
4.173.456
4.254.494
4.335.532
198
G-4-21-iii
4.773.615
4.916.824
5.012.296
5.107.768
199
G-4-22-i
1.929.531
1.987.417
2.026.008
2.064.598
200
G-4-22-ii
2.411.914
2.484.271
2.532.510
2.580.748
201
G-4-22-iii
2.767.096
2.850.109
2.905.451
2.960.793
202
G-4-23-i
1.929.531
1.987.417
2.026.008
2.064.598
203
G-4-23-ii
2.411.914
2.484.271
2.532.510
2.580.748
204
G-4-23-iii
3.447.660
3.551.090
3.620.043
3.688.996
205
G-4-24-i
1.929.531
1.987.417
2.026.008
2.064.598
206
G-4-24-ii
2.411.914
2.484.271
2.532.510
2.580.748
207
G-4-24-iii
TRAUMA KEPALA BERAT
5.068.376
5.220.427
5.321.795
5.423.162
208
G-4-25-i
GEGAR OTAK RINGAN
1.833.431
1.888.434
1.925.103
1.961.772
209
G-4-25-ii
GEGAR OTAK SEDANG
2.308.330
2.377.580
2.423.747
2.469.913
210
G-4-25-iii
GEGAR OTAK BERAT
3.011.733
3.102.085
3.162.319
3.222.554
211
G-4-26-i
2.894.297
2.981.126
3.039.012
3.096.897
212
G-4-26-ii
3.376.680
3.477.980
3.545.513
3.613.047
213
G-4-26-iii
6.445.609
6.638.977
6.767.889
6.896.801
214
H-1-20-i
2.773.492
2.856.697
2.912.167
2.967.636
215
H-1-20-ii
5.057.777
5.209.510
5.310.665
5.411.821
216
H-1-20-iii
6.878.260
7.084.608
7.222.173
7.359.738
217
H-1-30-i
2.715.513
2.796.978
2.851.288
2.905.599
218
H-1-30-ii
3.095.685
3.188.555
3.250.469
3.312.382
219
H-1-30-iii
5.165.038
5.319.989
5.423.290
5.526.590
220
H-4-10-i
2.894.297
2.981.126
3.039.012
3.096.897
221
H-4-10-ii
4.823.828
4.968.543
5.065.019
5.161.496
222
H-4-10-iii
7.864.264
8.100.192
8.257.477
8.414.763
223
H-4-11-i
1.970.698
2.029.819
2.069.233
2.108.647
224
H-4-11-ii
2.201.962
2.268.020
2.312.060
2.356.099
225
H-4-11-iii
3.148.599
3.243.057
3.306.029
3.369.001

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
RINGAN
SEDANG
RINGAN
SEDANG
- 389 No
Kode
INA-CBG
226
H-4-12-i
227
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.734.265
2.816.293
2.870.978
2.925.663
H-4-12-ii
3.703.741
3.814.853
3.888.928
3.963.002
228
H-4-12-iii
6.179.438
6.364.822
6.488.410
6.611.999
229
I-1-01-i
41.627.323
42.876.143
43.708.689
44.541.235
230
I-1-01-ii
42.543.341
43.819.641
44.670.508
45.521.375
231
I-1-01-iii
67.153.848
69.168.463
70.511.540
71.854.617
232
I-1-02-i
23.094.599
23.787.437
24.249.329
24.711.221
233
I-1-02-ii
29.792.033
30.685.794
31.281.634
31.877.475
234
I-1-02-iii
36.720.412
37.822.025
38.556.433
39.290.841
235
I-1-03-i
14.222.476
14.649.150
14.933.599
15.218.049
236
I-1-03-ii
19.494.351
20.079.182
20.469.069
20.858.956
237
I-1-03-iii
28.591.715
29.449.467
30.021.301
30.593.135
238
I-1-04-i
17.351.004
17.871.534
18.218.554
18.565.574
239
I-1-04-ii
22.287.672
22.956.302
23.402.056
23.847.809
240
I-1-04-iii
47.512.689
48.938.070
49.888.324
50.838.578
241
I-1-05-i
30.566.381
31.483.372
32.094.700
32.706.028
242
I-1-05-ii
36.679.657
37.780.047
38.513.640
39.247.233
243
I-1-05-iii
50.470.977
51.985.106
52.994.526
54.003.945
244
I-1-06-i
14.408.314
14.840.563
15.128.730
15.416.896
245
I-1-06-ii
21.745.566
22.397.933
22.832.844
23.267.756
246
I-1-06-iii
27.994.318
28.834.147
29.394.034
29.953.920
18.948.024
19.516.465
19.895.425
20.274.386
23.376.237
24.077.524
24.545.049
25.012.573
25.503.322
26.268.422
26.778.488
27.288.555
3.604.376
3.712.507
3.784.595
3.856.683
4.007.706
4.127.937
4.208.091
4.288.245
5.333.035
5.493.026
5.599.687
5.706.347
11.046.799
11.378.203
11.599.139
11.820.075
247
I-1-07-i
248
I-1-07-ii
249
I-1-07-iii
250
I-1-11-i
251
I-1-11-ii
252
I-1-11-iii
253
I-1-12-i

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
KATETERISASI RINGAN
KATETERISASI SEDANG
KATETERISASI BERAT
KOMPLEKS PADA JANTUNG ANOMALI
RINGAN
SEDANG
RINGAN
SEDANG
BERAT

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
- 390 No
Kode
INA-CBG
254
I-1-12-ii
255
I-1-12-iii
256
I-1-13-i
257
I-1-13-ii
258
I-1-13-iii
259
I-1-14-i
260
I-1-14-ii
261
I-1-14-iii
262
I-1-15-i
263
I-1-15-ii
264
I-1-15-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
15.327.949
15.787.788
16.094.347
16.400.906
21.378.871
22.020.237
22.447.815
22.875.392
6.498.117
6.693.061
6.823.023
6.952.985
7.560.161
7.786.966
7.938.169
8.089.372
13.781.668
14.195.118
14.470.751
14.746.385
23.773.852
24.487.067
24.962.544
25.438.021
29.547.502
30.433.927
31.024.877
31.615.827
38.717.416
39.878.938
40.653.287
41.427.635
4.658.535
4.798.291
4.891.462
4.984.632
13.646.046
14.055.427
14.328.348
14.601.269
70.633.971
72.752.990
74.165.669
75.578.349
10.188.794
10.494.457
10.698.233
10.902.009
26.490.863
27.285.589
27.815.407
28.345.224
30.556.561
31.473.258
32.084.389
32.695.520
3.267.628
3.365.657
3.431.009
3.496.362
6.768.442
6.971.496
7.106.864
7.242.233
39.239.311
40.416.491
41.201.277
41.986.063
3.898.870
4.015.836
4.093.814
4.171.791
7.017.966
7.228.505
7.368.864
7.509.224
9.357.289
9.638.007
9.825.153
10.012.299
11.559.239
11.906.017
12.137.201
12.368.386
24.045.553
24.766.920
25.247.831
25.728.742
37.261.874
38.379.730
39.124.968
39.870.205
15.544.571
16.010.908
16.321.800
16.632.691
21.588.070
22.235.712
22.667.474
23.099.235
27.050.842
27.862.367
28.403.384
28.944.401

KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

DARAH VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
265
I-1-16-i
266
I-1-16-ii
267
I-1-16-iii
268
I-1-17-i
269
I-1-17-ii
270
I-1-17-iii
271
I-1-20-i
272
I-1-20-ii
273
I-1-20-iii
274
I-1-30-i
275
I-1-30-ii
276
I-1-30-iii
277
I-1-40-i
278
I-1-40-ii
279
I-1-40-iii
280
I-4-10-i
4.520.813
4.656.437
4.746.854
4.837.270
281
I-4-10-ii
7.138.445
7.352.598
7.495.367
7.638.136
282
I-4-10-iii
10.297.829
10.606.764
10.812.721
11.018.677
- 391 No
Kode
INA-CBG
Deskripsi (INA-CBG)
283
I-4-11-i
284
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.360.502
5.521.317
5.628.527
5.735.737
I-4-11-ii
6.633.642
6.832.651
6.965.324
7.097.997
285
I-4-11-iii
11.739.972
12.092.171
12.326.970
12.561.770
286
I-4-12-i
4.695.243
4.836.100
4.930.005
5.023.909
287
I-4-12-ii
6.700.098
6.901.101
7.035.103
7.169.105
288
I-4-12-iii
8.128.161
8.372.006
8.534.569
8.697.132
4.217.618
4.344.147
4.428.499
4.512.852
6.127.339
6.311.159
6.433.706
6.556.253
12.541.952
12.918.211
13.169.050
13.419.889

VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
289
I-4-13-i
290
I-4-13-ii
291
I-4-13-iii
292
I-4-14-i
2.622.969
2.701.658
2.754.118
2.806.577
293
I-4-14-ii
3.069.262
3.161.340
3.222.725
3.284.110
294
I-4-14-iii
4.756.335
4.899.025
4.994.151
5.089.278
295
I-4-15-i
3.859.062
3.974.834
4.052.015
4.129.197
296
I-4-15-ii
5.524.439
5.690.172
5.800.661
5.911.149
297
I-4-15-iii
6.296.531
6.485.427
6.611.358
6.737.288
298
I-4-16-i
2.894.297
2.981.126
3.039.012
3.096.897
299
I-4-16-ii
4.690.658
4.831.378
4.925.191
5.019.004
300
I-4-16-iii
5.909.396
6.086.678
6.204.866
6.323.054
301
I-4-17-i
HIPERTENSI RINGAN
2.590.336
2.668.046
2.719.852
2.771.659
302
I-4-17-ii
HIPERTENSI SEDANG
3.668.173
3.778.218
3.851.582
3.924.945
303
I-4-17-iii
HIPERTENSI BERAT
4.462.508
4.596.383
4.685.633
4.774.883
304
I-4-18-i
3.814.820
3.929.265
4.005.561
4.081.858
305
I-4-18-ii
5.844.049
6.019.371
6.136.252
6.253.133
306
I-4-18-iii
7.878.715
8.115.077
8.272.651
8.430.225
307
I-4-19-i
2.985.597
3.075.165
3.134.877
3.194.589
308
I-4-19-ii
4.890.314
5.037.024
5.134.830
5.232.636
309
I-4-19-iii
5.829.210
6.004.086
6.120.671
6.237.255
310
I-4-20-i
3.623.445
3.732.148
3.804.617
3.877.086
311
I-4-20-ii
4.174.479
4.299.713
4.383.203
4.466.693
312
I-4-20-iii
5.540.228
5.706.435
5.817.240
5.928.044
313
I-4-21-i
4.818.595
4.963.153
5.059.525
5.155.897
314
I-4-21-ii
6.010.885
6.191.211
6.311.429
6.431.647
315
I-4-21-iii
8.200.121
8.446.125
8.610.127
8.774.130


RINGAN
SEDANG
KONGENITAL BERAT
RINGAN
SEDANG
BERAT
- 392 No
Kode
INA-CBG
316
I-4-22-i
317
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.135.488
3.229.553
3.292.263
3.354.972
I-4-22-ii
3.613.021
3.721.411
3.793.672
3.865.932
318
I-4-22-iii
5.271.299
5.429.438
5.534.864
5.640.290
319
I-4-23-i
2.375.309
2.446.568
2.494.075
2.541.581
320
I-4-23-ii
2.916.332
3.003.822
3.062.149
3.120.475
321
I-4-23-iii
5.698.247
5.869.195
5.983.160
6.097.125
322
I-4-24-i
2.833.058
2.918.050
2.974.711
3.031.372
323
I-4-24-ii
7.073.362
7.285.562
7.427.030
7.568.497
324
I-4-24-iii
8.942.988
9.211.278
9.390.137
9.568.997
325
J-1-01-i
28.577.465
29.434.789
30.006.339
30.577.888
326
J-1-01-ii
31.127.248
32.061.066
32.683.611
33.306.156
327
J-1-01-iii
46.155.918
47.540.595
48.463.714
49.386.832
328
J-1-02-i
12.926.863
13.314.669
13.573.207
13.831.744
329
J-1-02-ii
13.848.115
14.263.558
14.540.521
14.817.483
330
J-1-02-iii
20.463.568
21.077.475
21.486.746
21.896.018
331
J-1-10-i
5.044.249
5.195.576
5.296.461
5.397.346
332
J-1-10-ii
12.183.694
12.549.205
12.792.879
13.036.553
333
J-1-10-iii
21.572.728
22.219.910
22.651.365
23.082.819
334
J-1-20-i
4.359.845
4.490.641
4.577.837
4.665.034
335
J-1-20-ii
6.341.051
6.531.282
6.658.103
6.784.924
336
J-1-20-iii
9.534.981
9.821.031
10.011.731
10.202.430
337
J-1-30-i
2.940.084
3.028.287
3.087.089
3.145.890
338
J-1-30-ii
15.962.691
16.441.572
16.760.826
17.080.080
339
J-1-30-iii
48.142.776
49.587.060
50.549.915
51.512.771
340
J-4-10-i
3.761.816
3.874.670
3.949.906
4.025.143
341
J-4-10-ii
5.378.944
5.540.313
5.647.892
5.755.471
342
J-4-10-iii
8.137.540
8.381.666
8.544.417
8.707.168
343
J-4-11-i
2.140.709
2.204.930
2.247.744
2.290.559
344
J-4-11-ii
2.979.818
3.069.213
3.128.809
3.188.405
345
J-4-11-iii
4.270.155
4.398.260
4.483.663
4.569.066
346
J-4-12-i
EMBOLI PARU RINGAN
3.629.280
3.738.159
3.810.745
3.883.330

RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
- 393 No
Kode
INA-CBG
347
J-4-12-ii
348
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
EMBOLI PARU SEDANG
4.699.794
4.840.788
4.934.784
5.028.780
J-4-12-iii
EMBOLI PARU BERAT
6.276.100
6.464.383
6.589.905
6.715.427
349
J-4-13-i
5.042.741
5.194.023
5.294.878
5.395.733
350
J-4-13-ii
7.412.829
7.635.214
7.783.471
7.931.727
351
J-4-13-iii
12.052.151
12.413.716
12.654.759
12.895.802
352
J-4-14-i
TUMOR PARU RINGAN
3.554.935
3.661.583
3.732.682
3.803.780
353
J-4-14-ii
TUMOR PARU SEDANG
5.756.555
5.929.252
6.044.383
6.159.514
354
J-4-14-iii
TUMOR PARU BERAT
6.844.252
7.049.579
7.186.464
7.323.349
355
J-4-15-i
3.554.935
3.661.583
3.732.682
3.803.780
356
J-4-15-ii
4.236.143
4.363.228
4.447.950
4.532.673
357
J-4-15-iii
5.752.373
5.924.944
6.039.991
6.155.039
358
J-4-16-i
2.962.446
3.051.319
3.110.568
3.169.817
359
J-4-16-ii
4.147.424
4.271.847
4.354.795
4.437.744
360
J-4-16-iii
7.481.516
7.705.962
7.855.592
8.005.223
361
J-4-17-i
2.962.446
3.051.319
3.110.568
3.169.817
362
J-4-17-ii
PENYAKIT PARU OBSTRUKTIF KRONIS

SEDANG
3.554.935
3.661.583
3.732.682
3.803.780
363
J-4-17-iii
6.535.543
6.731.609
6.862.320
6.993.031
364
J-4-18-i
2.369.957
2.441.055
2.488.454
2.535.854
365
J-4-18-ii
3.258.690
3.356.451
3.421.625
3.486.799
366
J-4-18-iii
3.431.201
3.534.137
3.602.761
3.671.385
367
J-4-19-i
4.147.424
4.271.847
4.354.795
4.437.744
368
J-4-19-ii
4.739.913
4.882.111
4.976.909
5.071.707
369
J-4-19-iii
7.425.630
7.648.398
7.796.911
7.945.424
370
J-4-20-i
4.147.424
4.271.847
4.354.795
4.437.744
371
J-4-20-ii
4.739.913
4.882.111
4.976.909
5.071.707
372
J-4-20-iii
11.431.721
11.774.673
12.003.307
12.231.942
2.369.957
2.441.055
2.488.454
2.535.854
5.847.115
6.022.529
6.139.471
6.256.413
8.339.899
8.590.096
8.756.894
8.923.692
5.198.494
5.354.448
5.458.418
5.562.388
7.254.839
7.472.485
7.617.581
7.762.678
8.496.666
8.751.566
8.921.499
9.091.433
4.469.905
4.604.002
4.693.400
4.782.798
373
J-4-21-i
374
J-4-21-ii
375
J-4-21-iii
376
K-1-10-i
377
K-1-10-ii
378
K-1-10-iii
379
K-1-11-i

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT

USUS BESAR (RINGAN)
USUS BESAR (SEDANG)
USUS BESAR (BERAT)
RINGAN
- 394 No
Kode
INA-CBG
380
K-1-11-ii

SEDANG
381
K-1-11-iii
Deskripsi (INA-CBG)

Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.868.446
6.044.499
6.161.868
6.279.237
14.892.960
15.339.749
15.637.608
15.935.468
2.404.467
2.476.601
2.524.690
2.572.779
3.133.764
3.227.777
3.290.452
3.353.127
6.233.715
6.420.727
6.545.401
6.670.076
382
K-1-12-i
383
K-1-12-ii
384
K-1-12-iii
385
K-1-13-i
2.731.145
2.813.079
2.867.702
2.922.325
386
K-1-13-ii
4.770.525
4.913.641
5.009.052
5.104.462
387
K-1-13-iii
5.101.905
5.254.962
5.357.000
5.459.038
388
K-1-14-i
4.413.691
4.546.102
4.634.376
4.722.650
389
K-1-14-ii
5.184.381
5.339.912
5.443.600
5.547.287
390
K-1-14-iii
12.765.448
13.148.412
13.403.721
13.659.030
391
K-1-20-i
8.563.856
8.820.772
8.992.049
9.163.326
392
K-1-20-ii
11.952.885
12.311.471
12.550.529
12.789.587
393
K-1-20-iii
25.531.926
26.297.884
26.808.523
27.319.161
394
K-1-30-i
5.637.156
5.806.271
5.919.014
6.031.757
395
K-1-30-ii
10.396.987
10.708.897
10.916.837
11.124.776
396
K-1-30-iii
16.191.974
16.677.733
17.001.573
17.325.412
397
K-1-40-i
5.663.204
5.833.100
5.946.364
6.059.628
398
K-1-40-ii
6.231.794
6.418.747
6.543.383
6.668.019
399
K-1-40-iii
10.334.830
10.644.874
10.851.571
11.058.268
400
K-1-50-i
4.319.658
4.449.248
4.535.641
4.622.034
401
K-1-50-ii
5.594.161
5.761.986
5.873.869
5.985.753
402
K-1-50-iii
PROSEDUR ANAL BERAT
7.942.221
8.180.488
8.339.332
8.498.177
403
K-4-10-i
3.271.830
3.369.985
3.435.422
3.500.859
404
K-4-10-ii
3.914.937
4.032.385
4.110.684
4.188.983
405
K-4-10-iii
16.211.704
16.698.056
17.022.290
17.346.524
406
K-4-11-i
1.929.531
1.987.417
2.026.008
2.064.598
407
K-4-11-ii
2.894.297
2.981.126
3.039.012
3.096.897
408
K-4-11-iii
5.259.980
5.417.779
5.522.979
5.628.179
409
K-4-12-i
1.929.531
1.987.417
2.026.008
2.064.598
410
K-4-12-ii
2.882.690
2.969.170
3.026.824
3.084.478
411
K-4-12-iii
6.918.250
7.125.797
7.264.162
7.402.527
412
K-4-13-i

(RINGAN)
2.894.297
2.981.126
3.039.012
3.096.897

RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
- 395 No
Kode
INA-CBG
413
K-4-13-ii
414
K-4-13-iii
415
K-4-14-i
416
K-4-14-ii
417
K-4-14-iii
418
K-4-15-i
419
K-4-15-ii
420
K-4-15-iii
421
K-4-16-i
422
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.748.827
3.861.292
3.936.268
4.011.245
6.131.440
6.315.383
6.438.012
6.560.641
2.411.914
2.484.271
2.532.510
2.580.748
3.264.274
3.362.202
3.427.487
3.492.773
4.937.525
5.085.651
5.184.402
5.283.152
2.411.914
2.484.271
2.532.510
2.580.748
4.535.056
4.671.108
4.761.809
4.852.510
6.452.568
6.646.146
6.775.197
6.904.248
2.411.914
2.484.271
2.532.510
2.580.748
K-4-16-ii
2.894.297
2.981.126
3.039.012
3.096.897
423
K-4-16-iii
3.532.865
3.638.851
3.709.508
3.780.166
424
K-4-17-i
1.929.531
1.987.417
2.026.008
2.064.598
425
K-4-17-ii
2.815.222
2.899.679
2.955.983
3.012.288
426
K-4-17-iii
3.746.773
3.859.176
3.934.112
4.009.047
427
K-4-18-i
1.929.531
1.987.417
2.026.008
2.064.598
428
K-4-18-ii
2.995.433
3.085.296
3.145.204
3.205.113
429
K-4-18-iii
3.543.582
3.649.889
3.720.761
3.791.633
430
L-1-20-i
19.745.377
20.337.739
20.732.646
21.127.554
431
L-1-20-ii
20.540.636
21.156.855
21.567.667
21.978.480
432
L-1-20-iii
31.470.625
32.414.744
33.044.156
33.673.569
433
L-1-30-i
8.955.922
9.224.599
9.403.718
9.582.836
434
L-1-30-ii
12.972.682
13.361.862
13.621.316
13.880.769
435
L-1-30-iii
13.682.131
14.092.595
14.366.238
14.639.881
436
L-1-40-i
3.616.141
3.724.625
3.796.948
3.869.270
437
L-1-40-ii
8.138.847
8.383.013
8.545.790
8.708.567
438
L-1-40-iii
13.793.195
14.206.991
14.482.855
14.758.719
439
L-1-50-i
6.498.117
6.693.061
6.823.023
6.952.985
440
L-1-50-ii
11.696.611
12.047.509
12.281.441
12.515.373
441
L-1-50-iii
14.142.857
14.567.143
14.850.000
15.132.857
442
L-4-10-i
2.894.297
2.981.126
3.039.012
3.096.897
443
L-4-10-ii
3.376.680
3.477.980
3.545.513
3.613.047

(SEDANG)
RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
- 396 No
Kode
INA-CBG
444
L-4-10-iii
445
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
6.830.734
7.035.656
7.172.271
7.308.885
L-4-11-i
2.737.478
2.819.602
2.874.351
2.929.101
446
L-4-11-ii
3.750.296
3.862.805
3.937.811
4.012.817
447
L-4-11-iii
10.170.335
10.475.445
10.678.852
10.882.258
448
L-4-12-i
2.894.297
2.981.126
3.039.012
3.096.897
449
L-4-12-ii
4.246.605
4.374.003
4.458.935
4.543.867
450
L-4-12-iii
7.121.054
7.334.685
7.477.106
7.619.528
451
L-4-13-i
1.816.663
1.871.163
1.907.496
1.943.829
452
L-4-13-ii
2.094.719
2.157.561
2.199.455
2.241.350
453
L-4-13-iii
3.142.242
3.236.509
3.299.354
3.362.199
454
L-4-14-i
1.929.531
1.987.417
2.026.008
2.064.598
455
L-4-14-ii
2.894.297
2.981.126
3.039.012
3.096.897
456
L-4-14-iii
4.525.285
4.661.044
4.751.549
4.842.055
457
M-1-01-i
9.407.216
9.689.433
9.877.577
10.065.721
458
M-1-01-ii
10.499.975
10.814.974
11.024.974
11.234.973
459
M-1-01-iii
14.749.620
15.192.109
15.487.101
15.782.094
460
M-1-02-i
6.662.708
6.862.590
6.995.844
7.129.098
461
M-1-02-ii
10.938.900
11.267.067
11.485.845
11.704.623
462
M-1-02-iii
19.809.847
20.404.142
20.800.339
21.196.536
463
M-1-03-i
16.895.104
17.401.957
17.739.860
18.077.762
464
M-1-03-ii
19.772.213
20.365.379
20.760.824
21.156.268
465
M-1-03-iii
20.144.163
20.748.488
21.151.371
21.554.254
466
M-1-04-i
4.395.189
4.527.045
4.614.948
4.702.852
467
M-1-04-ii
5.634.587
5.803.624
5.916.316
6.029.008
468
M-1-04-iii
7.050.623
7.262.142
7.403.154
7.544.167
469
M-1-05-i
6.846.860
7.052.266
7.189.203
7.326.141
470
M-1-05-ii
7.913.136
8.150.530
8.308.793
8.467.055
471
M-1-05-iii
13.478.226
13.882.572
14.152.137
14.421.701
472
M-1-07-i
7.557.975
7.784.715
7.935.874
8.087.034
473
M-1-07-ii
10.125.325
10.429.085
10.631.592
10.834.098
474
M-1-07-iii
20.626.248
21.245.035
21.657.560
22.070.085
475
M-1-10-i
4.723.589
4.865.297
4.959.769
5.054.241


TULANG WAJAH RINGAN
- 397 No
Kode
INA-CBG
476
M-1-10-ii
477
M-1-10-iii
478
M-1-20-i
479
M-1-20-ii
480
M-1-20-iii
481
M-1-30-i
482
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
17.545.994
18.072.374
18.423.294
18.774.214
21.462.095
22.105.958
22.535.200
22.964.442
4.672.850
4.813.036
4.906.493
4.999.950
6.670.074
6.870.177
7.003.578
7.136.980
12.965.171
13.354.126
13.613.429
13.872.733
2.795.063
2.878.915
2.934.816
2.990.717
M-1-30-ii
5.775.311
5.948.571
6.064.077
6.179.583
483
M-1-30-iii
PROSEDUR KAKI BERAT
8.615.547
8.874.013
9.046.324
9.218.635
484
M-1-40-i
2.824.194
2.908.920
2.965.404
3.021.888
485
M-1-40-ii
5.198.494
5.354.448
5.458.418
5.562.388
486
M-1-40-iii
9.097.364
9.370.285
9.552.232
9.734.179
487
M-1-50-i
3.740.289
3.852.498
3.927.304
4.002.109
488
M-1-50-ii
7.529.290
7.755.169
7.905.754
8.056.340
489
M-1-50-iii
10.396.987
10.708.897
10.916.837
11.124.776
490
M-1-60-i
2.822.738
2.907.420
2.963.875
3.020.330
491
M-1-60-ii
5.651.140
5.820.674
5.933.697
6.046.720
492
M-1-60-iii
9.834.982
10.130.032
10.326.732
10.523.431
493
M-1-70-i
3.781.334
3.894.774
3.970.401
4.046.027
494
M-1-70-ii
7.715.794
7.947.268
8.101.584
8.255.900
495
M-1-70-iii
12.438.792
12.811.956
13.060.732
13.309.508
496
M-1-80-i
3.046.732
3.138.134
3.199.068
3.260.003
497
M-1-80-ii
4.606.036
4.744.217
4.836.337
4.928.458
498
M-1-80-iii
10.604.287
10.922.416
11.134.501
11.346.587
499
M-4-10-i
1.929.531
1.987.417
2.026.008
2.064.598
500
M-4-10-ii
2.943.980
3.032.299
3.091.179
3.150.059
501
M-4-10-iii
FRAKTUR FEMUR BERAT
6.251.386
6.438.927
6.563.955
6.688.983
502
M-4-11-i
2.553.636
2.630.245
2.681.318
2.732.391
503
M-4-11-ii
5.858.422
6.034.175
6.151.343
6.268.512
504
M-4-11-iii
10.398.562
10.710.519
10.918.490
11.126.461
505
M-4-12-i
1.929.531
1.987.417
2.026.008
2.064.598

TULANG WAJAH SEDANG
TULANG WAJAH BERAT

RINGAN
SEDANG
BERAT

JARINGAN PENGHUBUNG LAIN-LAIN
(RINGAN)
(SEDANG)
SELAIN KAKI (BERAT)

PANGGUL RINGAN
PANGGUL SEDANG
PANGGUL BERAT
PELVIS RINGAN
- 398 No
Kode
INA-CBG
506
M-4-12-ii
507
M-4-12-iii
508
M-4-13-i
509
M-4-13-ii
510
M-4-13-iii
511
M-4-14-i
512
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.510.780
3.616.103
3.686.319
3.756.534
7.031.173
7.242.108
7.382.732
7.523.355
3.562.085
3.668.947
3.740.189
3.811.431
4.823.828
4.968.543
5.065.019
5.161.496
10.596.310
10.914.199
11.126.126
11.338.052
3.859.062
3.974.834
4.052.015
4.129.197
M-4-14-ii
5.010.098
5.160.401
5.260.602
5.360.804
513
M-4-14-iii
OSTEOMIELITIS BERAT
7.504.586
7.729.724
7.879.815
8.029.907
514
M-4-15-i
2.407.642
2.479.871
2.528.024
2.576.177
515
M-4-15-ii
3.210.392
3.306.704
3.370.912
3.435.120
516
M-4-15-iii
8.200.507
8.446.523
8.610.533
8.774.543
517
M-4-16-i
2.411.914
2.484.271
2.532.510
2.580.748
518
M-4-16-ii
3.859.062
3.974.834
4.052.015
4.129.197
519
M-4-16-iii
7.175.650
7.390.920
7.534.433
7.677.946
2.411.914
2.484.271
2.532.510
2.580.748
3.376.680
3.477.980
3.545.513
3.613.047
4.715.712
4.857.184
4.951.498
5.045.812
2.827.138
2.911.952
2.968.495
3.025.037
3.859.062
3.974.834
4.052.015
4.129.197
4.794.661
4.938.500
5.034.394
5.130.287
2.102.015
2.165.076
2.207.116
2.249.156
3.540.467
3.646.681
3.717.490
3.788.299
6.914.793
7.122.237
7.260.533
7.398.829
1.929.531
1.987.417
2.026.008
2.064.598
2.894.297
2.981.126
3.039.012
3.096.897
3.207.563
3.303.790
3.367.941
3.432.092
1.929.531
1.987.417
2.026.008
2.064.598
2.518.523
2.594.079
2.644.450
2.694.820
6.139.097
6.323.270
6.446.052
6.568.834
520
M-4-17-i
521
M-4-17-ii
522
M-4-17-iii
523
M-4-18-i
524
M-4-18-ii
525
M-4-18-iii
526
M-4-19-i
527
M-4-19-ii
528
M-4-19-iii
529
M-4-20-i
530
M-4-20-ii
531
M-4-20-iii
532
M-4-21-i
533
M-4-21-ii
534
M-4-21-iii

PELVIS SEDANG
PELVIS BERAT

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
RINGAN
SEDANG
BERAT
ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
KESELEO DAN PERADANGAN MINOR
(RINGAN)
(SEDANG)
(RINGAN)
(SEDANG)
- 399 No
Kode
INA-CBG
535
N-1-01-i
536
N-1-01-ii
537
N-1-01-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.220.789
5.377.413
5.481.829
5.586.245
7.061.000
7.272.830
7.414.050
7.555.270
14.971.420
15.420.563
15.719.991
16.019.419
7.202.482
7.418.556
7.562.606
7.706.656
9.741.194
10.033.430
10.228.254
10.423.078
20.654.230
21.273.857
21.686.941
22.100.026
3.898.870
4.015.836
4.093.814
4.171.791
9.070.446
9.342.559
9.523.968
9.705.377
16.531.452
17.027.396
17.358.025
17.688.654

RINGAN
SEDANG
BERAT
538
N-1-11-i
539
N-1-11-ii
540
N-1-11-iii
541
N-1-12-i
542
N-1-12-ii
543
N-1-12-iii
544
N-1-20-i
5.278.762
5.437.125
5.542.700
5.648.276
545
N-1-20-ii
10.465.909
10.779.886
10.989.205
11.198.523
546
N-1-20-iii
11.972.051
12.331.213
12.570.654
12.810.095
547
N-1-30-i
6.280.020
6.468.420
6.594.020
6.719.621
548
N-1-30-ii
9.543.273
9.829.571
10.020.437
10.211.302
549
N-1-30-iii
10.985.881
11.315.457
11.535.175
11.754.892
550
N-1-40-i
5.658.912
5.828.680
5.941.858
6.055.036
551
N-1-40-ii
7.670.857
7.900.983
8.054.400
8.207.817
552
N-1-40-iii
8.921.429
9.189.072
9.367.500
9.545.929
553
N-4-10-i
2.411.914
2.484.271
2.532.510
2.580.748
554
N-4-10-ii
3.229.620
3.326.509
3.391.101
3.455.694
555
N-4-10-iii
7.069.057
7.281.129
7.422.510
7.563.891
556
N-4-11-i
1.847.051
1.902.463
1.939.404
1.976.345
557
N-4-11-ii
3.121.472
3.215.116
3.277.546
3.339.975
558
N-4-11-iii
3.617.871
3.726.407
3.798.764
3.871.122
559
N-4-12-i
1.929.531
1.987.417
2.026.008
2.064.598
560
N-4-12-ii
2.894.297
2.981.126
3.039.012
3.096.897
561
N-4-12-iii
4.805.484
4.949.648
5.045.758
5.141.868
562
N-4-13-i
BATU URIN RINGAN
2.545.645
2.622.014
2.672.927
2.723.840
563
N-4-13-ii
BATU URIN SEDANG
3.069.090
3.161.163
3.222.545
3.283.927
564
N-4-13-iii
BATU URIN BERAT
7.558.327
7.785.077
7.936.244
8.087.410
1.671.332
1.721.472
1.754.898
1.788.325
2.573.640
2.650.850
2.702.322
2.753.795
565
N-4-14-i
566
N-4-14-ii

URIN BAWAH RINGAN
URIN BAWAH SEDANG
URIN BAWAH BERAT
RINGAN
SEDANG
BERAT
GINJAL RINGAN
GINJAL SEDANG
GINJAL BERAT

(RINGAN)
(SEDANG)
- 400 No
Kode
INA-CBG
567
N-4-14-iii
568
N-4-15-i
569
N-4-15-ii
570
N-4-15-iii
571
N-4-16-i
572
N-4-16-ii
573
N-4-16-iii
574
O-6-10-i
575
O-6-10-ii
576
O-6-10-iii
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
584
585
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.173.624
4.298.833
4.382.306
4.465.778
2.479.551
2.553.937
2.603.528
2.653.119
3.402.715
3.504.797
3.572.851
3.640.905
3.883.112
3.999.605
4.077.268
4.154.930
3.218.114
3.314.658
3.379.020
3.443.382
3.859.062
3.974.834
4.052.015
4.129.197
8.115.034
8.358.485
8.520.786
8.683.086
4.751.704
4.894.256
4.989.290
5.084.324
5.275.116
5.433.370
5.538.872
5.644.374
5.913.469
6.090.873
6.209.142
6.327.411
2.483.411
2.557.913
2.607.581
2.657.249
3.185.989
3.281.569
3.345.289
3.409.008
5.399.263
5.561.241
5.669.226
5.777.211
2.162.566
2.227.443
2.270.694
2.313.945
2.597.236
2.675.153
2.727.098
2.779.042
3.263.055
3.360.946
3.426.208
3.491.469
2.167.281
2.232.299
2.275.645
2.318.990
O-6-13-ii
3.194.146
3.289.971
3.353.854
3.417.737
O-6-13-iii
3.774.988
3.888.237
3.963.737
4.039.237
48.481.088
49.935.521
50.905.143
51.874.764
59.987.763
61.787.396
62.987.151
64.186.906
70.408.818
72.521.082
73.929.258
75.337.435
58.738.622
60.500.781
61.675.553
62.850.326
67.379.246
69.400.623
70.748.208
72.095.793
76.985.606
79.295.174
80.834.886
82.374.598
3.249.059
3.346.530
3.411.511
3.476.493
4.548.682
4.685.142
4.776.116
4.867.090
7.165.206
7.380.162
7.523.466
7.666.770
586
P-8-01-i
587
P-8-01-ii
588
P-8-01-iii
589
P-8-02-i
590
P-8-02-ii
591
P-8-02-iii
592
P-8-03-i
593
P-8-03-ii
594
P-8-03-iii

(BERAT)
SALURAN URIN RINGAN
SALURAN URIN SEDANG
SALURAN URIN BERAT
RINGAN
SEDANG
BERAT
&KURET RINGAN
KURET SEDANG
KURET BERAT

- 401 No
Kode
INA-CBG
595
P-8-04-i
596
P-8-04-ii
597
P-8-04-iii
598
P-8-05-i
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii
603
P-8-06-iii
604
P-8-07-i
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
614
P-8-11-ii
615
P-8-11-iii
616
P-8-12-i
617
P-8-12-ii
618
P-8-12-iii
619
P-8-13-i
620
P-8-13-ii
621
P-8-13-iii
622
P-8-14-i
Deskripsi (INA-CBG)
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
RINGAN
SEDANG
BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
29.016.375
29.886.866
30.467.193
31.047.521
37.656.998
38.786.708
39.539.848
40.292.988
53.990.657
55.610.377
56.690.190
57.770.003
15.778.164
16.251.509
16.567.072
16.882.635
22.363.420
23.034.323
23.481.591
23.928.859
32.949.497
33.937.982
34.596.972
35.255.962
2.599.247
2.677.224
2.729.209
2.781.194
6.540.386
6.736.598
6.867.405
6.998.213
12.165.864
12.530.840
12.774.157
13.017.475
4.548.682
4.685.142
4.776.116
4.867.090
12.753.409
13.136.012
13.391.080
13.646.148
16.895.104
17.401.957
17.739.860
18.077.762
3.296.347
3.395.237
3.461.164
3.527.091
4.679.628
4.820.017
4.913.610
5.007.202
6.606.198
6.804.384
6.936.508
7.068.632
2.045.050
2.106.401
2.147.302
2.188.203
2.962.552
3.051.429
3.110.680
3.169.931
5.816.363
5.990.854
6.107.181
6.223.509
5.759.730
5.932.521
6.047.716
6.162.911
12.262.306
12.630.176
12.875.422
13.120.668
12.519.204
12.894.780
13.145.164
13.395.548
2.717.289
2.798.808
2.853.154
2.907.500
4.224.913
4.351.660
4.436.159
4.520.657
4.984.504
5.134.039
5.233.729
5.333.419
1.404.442
1.446.575
1.474.664
1.502.752
2.598.908
2.676.875
2.728.854
2.780.832
3.886.945
4.003.553
4.081.292
4.159.031
2.566.061
2.643.043
2.694.364
2.745.685
- 402 No
Kode
INA-CBG
623
P-8-14-ii
624
P-8-14-iii
625
P-8-15-i
626
P-8-15-ii
627
P-8-15-iii
628
P-8-16-i
629
P-8-16-ii
630
P-8-16-iii
631
P-8-17-i
632
P-8-17-ii
633
P-8-17-iii
634
S-4-10-i
635
S-4-10-ii
636
S-4-10-iii
637
S-4-11-i
638
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.239.170
5.396.345
5.501.128
5.605.912
5.747.350
5.919.770
6.034.717
6.149.664
1.929.758
1.987.650
2.026.246
2.064.841
3.857.078
3.972.791
4.049.932
4.127.074
4.530.736
4.666.658
4.757.272
4.847.887
1.746.887
1.799.293
1.834.231
1.869.169
2.478.034
2.552.375
2.601.935
2.651.496
3.216.609
3.313.108
3.377.440
3.441.772
1.152.941
1.187.530
1.210.589
1.233.647
3.829.682
3.944.572
4.021.166
4.097.759
7.729.968
7.961.867
8.116.467
8.271.066
1.929.531
1.987.417
2.026.008
2.064.598
2.411.914
2.484.271
2.532.510
2.580.748
3.135.074
3.229.126
3.291.828
3.354.529
1.205.957
1.242.136
1.266.255
1.290.374
S-4-11-ii
1.835.489
1.890.554
1.927.264
1.963.974
639
S-4-11-iii
2.969.501
3.058.586
3.117.976
3.177.366
640
S-4-12-i
1.447.148
1.490.563
1.519.506
1.548.449
641
S-4-12-ii
EFEK TOKSIK DAN KERACUNAN OBAT

SEDANG
1.929.531
1.987.417
2.026.008
2.064.598
642
S-4-12-iii
3.768.527
3.881.583
3.956.953
4.032.324
1.929.531
1.987.417
2.026.008
2.064.598
3.410.978
3.513.308
3.581.527
3.649.747
6.945.186
7.153.541
7.292.445
7.431.349
1.175.628
1.210.897
1.234.409
1.257.922
2.497.428
2.572.351
2.622.299
2.672.248
4.736.013
4.878.093
4.972.814
5.067.534
889.138
915.812
933.595
951.378
1.678.107
1.728.450
1.762.012
1.795.574
2.173.538
2.238.744
2.282.215
2.325.686

ASPIRASI RINGAN
ASPIRASI SEDANG
ASPIRASI BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT

PASIEN RINGAN
PASIEN SEDANG
PASIEN BERAT
643
S-4-13-i
644
S-4-13-ii
645
S-4-13-iii
646
S-4-14-i
647
S-4-14-ii
648
S-4-14-iii
649
S-4-15-i
650
S-4-15-ii
651
S-4-15-iii
652
S-4-16-i
LUKA BAKAR RINGAN
3.376.680
3.477.980
3.545.513
3.613.047
653
S-4-16-ii
LUKA BAKAR SEDANG
4.768.971
4.912.041
5.007.420
5.102.799
654
S-4-16-iii
LUKA BAKAR BERAT
8.515.739
8.771.211
8.941.526
9.111.841
- 403 No
Kode
INA-CBG
655
S-4-17-i
656
S-4-17-ii
657
S-4-17-iii
658
T-1-10-i
659
T-1-10-ii
660
T-1-10-iii
661
T-4-10-i
662
T-4-10-ii
663
T-4-10-iii
664
T-4-11-i
665
T-4-11-ii
666
T-4-11-iii
667
T-4-12-i
668
T-4-12-ii
669
T-4-12-iii
670
U-1-10-i
671
U-1-10-ii
672
U-1-10-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.800.512
1.854.527
1.890.537
1.926.548
2.411.914
2.484.271
2.532.510
2.580.748
3.933.102
4.051.095
4.129.757
4.208.419
1.858.625
1.914.384
1.951.556
1.988.729
2.496.007
2.570.888
2.620.808
2.670.728
4.541.051
4.677.282
4.768.103
4.858.924
813.016
837.406
853.666
869.927
1.549.427
1.595.910
1.626.899
1.657.887
2.252.447
2.320.020
2.365.069
2.410.118
804.026
828.147
844.227
860.308
1.265.308
1.303.267
1.328.573
1.353.879
2.038.038
2.099.179
2.139.940
2.180.701
1.688.340
1.738.990
1.772.757
1.806.524
2.551.833
2.628.388
2.679.424
2.730.461
3.969.735
4.088.827
4.168.221
4.247.616
1.797.083
1.850.996
1.886.937
1.922.879
3.667.058
3.777.070
3.850.411
3.923.752
15.835.098
16.310.151
16.626.853
16.943.555

DOKTER RINGAN
DOKTER SEDANG
DOKTER BERAT

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
7.797.740
8.031.673
8.187.627
8.343.582
10.396.987
10.708.897
10.916.837
11.124.776
17.467.864
17.991.900
18.341.257
18.690.615
673
U-1-11-i
674
U-1-11-ii
675
U-1-11-iii
676
U-1-12-i
4.765.283
4.908.242
5.003.548
5.098.853
677
U-1-12-ii
11.696.611
12.047.509
12.281.441
12.515.373
678
U-1-12-iii
15.188.270
15.643.919
15.947.684
16.251.449
679
U-1-13-i
5.198.494
5.354.448
5.458.418
5.562.388
680
U-1-13-ii
5.865.311
6.041.271
6.158.577
6.275.883
681
U-1-13-iii
11.309.974
11.649.274
11.875.473
12.101.673
2.868.365
2.954.416
3.011.784
3.069.151
3.520.061
3.625.663
3.696.064
3.766.465
4.171.371
4.296.513
4.379.940
4.463.367
1.684.700
1.735.241
1.768.935
1.802.629
682
U-1-14-i
683
U-1-14-ii
684
U-1-14-iii
685
U-1-15-i

- 404 No
Kode
INA-CBG
686
U-1-15-ii
687
U-1-15-iii
688
U-1-20-i
689
U-1-20-ii
690
U-1-20-iii
691
U-1-30-i
692
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.393.842
2.465.657
2.513.534
2.561.410
4.717.161
4.858.676
4.953.019
5.047.362
4.357.586
4.488.314
4.575.465
4.662.617
7.756.503
7.989.198
8.144.328
8.299.458
19.135.576
19.709.643
20.092.355
20.475.066
3.738.049
3.850.190
3.924.951
3.999.712
U-1-30-ii
5.046.366
5.197.757
5.298.684
5.399.612
693
U-1-30-iii
9.892.328
10.189.098
10.386.945
10.584.791
694
U-4-10-i
3.479.499
3.583.884
3.653.474
3.723.064
695
U-4-10-ii
8.722.374
8.984.045
9.158.492
9.332.940
696
U-4-10-iii
12.724.044
13.105.765
13.360.246
13.614.727
697
U-4-11-i
1.929.531
1.987.417
2.026.008
2.064.598
698
U-4-11-ii
2.894.297
2.981.126
3.039.012
3.096.897
699
U-4-11-iii
4.002.801
4.122.885
4.202.941
4.282.997
700
U-4-12-i
1.929.531
1.987.417
2.026.008
2.064.598
701
U-4-12-ii
2.249.389
2.316.871
2.361.858
2.406.846
702
U-4-12-iii
3.576.426
3.683.719
3.755.247
3.826.776
703
U-4-13-i
1.895.622
1.952.491
1.990.403
2.028.316
704
U-4-13-ii
2.203.772
2.269.885
2.313.960
2.358.036
705
U-4-13-iii
2.502.221
2.577.288
2.627.332
2.677.377
706
U-4-14-i
2.411.914
2.484.271
2.532.510
2.580.748
707
U-4-14-ii
2.894.297
2.981.126
3.039.012
3.096.897
708
U-4-14-iii
4.848.449
4.993.903
5.090.872
5.187.841
1.929.531
1.987.417
2.026.008
2.064.598
2.411.914
2.484.271
2.532.510
2.580.748
3.377.334
3.478.654
3.546.201
3.613.747
5.640.659
5.809.879
5.922.692
6.035.505
6.498.117
6.693.061
6.823.023
6.952.985
12.346.422
12.716.815
12.963.744
13.210.672


DAN TELINGA RINGAN
DAN TELINGA SEDANG
DAN TELINGA BERAT


KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT
709
U-4-15-i
710
U-4-15-ii
711
U-4-15-iii
712
V-1-10-i
713
V-1-10-ii
714
V-1-10-iii
715
V-1-11-i
6.498.117
6.693.061
6.823.023
6.952.985
716
V-1-11-ii
7.252.008
7.469.568
7.614.608
7.759.648
717
V-1-11-iii
10.739.113
11.061.286
11.276.069
11.490.851
718
V-1-12-i

3.509.506
3.614.791
3.684.981
3.755.171
- 405 No
Kode
INA-CBG
719
V-1-12-ii
720
V-1-12-iii
721
V-1-13-i
722
V-1-13-ii
723
V-1-13-iii
724
V-1-14-i
725
V-1-14-ii
726
V-1-14-iii
727
V-1-15-i
728
V-1-15-ii
729
V-1-15-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
13.412.165
13.814.530
14.082.773
14.351.016
15.659.924
16.129.722
16.442.921
16.756.119
5.319.273
5.478.851
5.585.237
5.691.622
10.108.145
10.411.390
10.613.553
10.815.716
15.595.481
16.063.345
16.375.255
16.687.165
6.412.446
6.604.819
6.733.068
6.861.317
9.326.353
9.606.143
9.792.670
9.979.197
12.677.820
13.058.154
13.311.711
13.565.267
3.023.111
3.113.804
3.174.267
3.234.729
5.758.438
5.931.191
6.046.360
6.161.529
10.123.224
10.426.921
10.629.385
10.831.850
4.867.972
5.014.011
5.111.371
5.208.730
6.287.567
6.476.194
6.601.946
6.727.697
12.016.645
12.377.144
12.617.477
12.857.810
2.475.546
2.549.812
2.599.323
2.648.834
3.617.168
3.725.683
3.798.027
3.870.370
5.968.088
6.147.131
6.266.493
6.385.854
7.279.318
7.497.697
7.643.284
7.788.870
8.767.593
9.030.621
9.205.973
9.381.324
19.365.871
19.946.847
20.334.165
20.721.482

NON KOMPLEK (BERAT)

RINGAN
SEDANG
BERAT
730
V-4-10-i
731
V-4-10-ii
732
V-4-10-iii
733
V-4-11-i
734
V-4-11-ii
735
V-4-11-iii
736
W-1-01-i
737
W-1-01-ii
738
W-1-01-iii
739
W-1-10-i
2.027.281
2.088.100
2.128.645
2.169.191
740
W-1-10-ii
3.783.239
3.896.737
3.972.401
4.048.066
741
W-1-10-iii
6.188.179
6.373.825
6.497.588
6.621.352
742
W-1-11-i
2.105.671
2.168.841
2.210.955
2.253.068
743
W-1-11-ii
4.061.053
4.182.885
4.264.106
4.345.327
744
W-1-11-iii
7.797.740
8.031.673
8.187.627
8.343.582
745
W-1-12-i
1.913.319
1.970.718
2.008.985
2.047.251
746
W-1-12-ii
2.175.407
2.240.669
2.284.177
2.327.685
747
W-1-12-iii
3.341.699
3.441.950
3.508.784
3.575.618
748
W-1-13-i
2.277.301
2.345.620
2.391.166
2.436.712
749
W-1-13-ii
2.472.493
2.546.668
2.596.118
2.645.567
750
W-1-13-iii
3.321.014
3.420.645
3.487.065
3.553.485

SERVIK RINGAN
SERVIK SEDANG
SERVIK BERAT
ENDOSKOP RINGAN
ENDOSKOP SEDANG
ENDOSKOP BERAT
- 406 No
Kode
INA-CBG
Deskripsi (INA-CBG)
751
W-1-20-i
752
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
6.204.997
6.391.147
6.515.247
6.639.347
W-1-20-ii
8.728.260
8.990.108
9.164.673
9.339.238
753
W-1-20-iii
11.026.252
11.357.040
11.577.565
11.798.090
754
W-1-30-i
3.387.306
3.488.926
3.556.672
3.624.418
755
W-1-30-ii
5.402.929
5.565.017
5.673.075
5.781.134
756
W-1-30-iii
14.367.717
14.798.749
15.086.103
15.373.457
757
W-4-10-i
2.526.082
2.601.864
2.652.386
2.702.908
758
W-4-10-ii
3.414.283
3.516.711
3.584.997
3.653.282
759
W-4-10-iii
7.718.125
7.949.668
8.104.031
8.258.393
760
W-4-11-i
2.411.914
2.484.271
2.532.510
2.580.748
761
W-4-11-ii
3.859.062
3.974.834
4.052.015
4.129.197
762
W-4-11-iii
4.689.904
4.830.602
4.924.400
5.018.198
763
W-4-12-i
1.929.531
1.987.417
2.026.008
2.064.598
764
W-4-12-ii
2.653.105
2.732.698
2.785.761
2.838.823
765
W-4-12-iii
2.957.918
3.046.655
3.105.814
3.164.972
766
W-4-13-i
ABORTUS RINGAN
1.058.178
1.089.923
1.111.087
1.132.250
767
W-4-13-ii
ABORTUS SEDANG
1.447.148
1.490.563
1.519.506
1.548.449
768
W-4-13-iii
ABORTUS BERAT
1.929.531
1.987.417
2.026.008
2.064.598
769
W-4-14-i
1.447.148
1.490.563
1.519.506
1.548.449
770
W-4-14-ii
1.861.266
1.917.104
1.954.330
1.991.555
771
W-4-14-iii
2.342.043
2.412.304
2.459.145
2.505.986
772
W-4-15-i
1.206.753
1.242.956
1.267.091
1.291.226
773
W-4-15-ii
1.342.140
1.382.404
1.409.247
1.436.089
774
W-4-15-iii
1.858.320
1.914.069
1.951.236
1.988.402
775
W-4-16-i
1.447.148
1.490.563
1.519.506
1.548.449
776
W-4-16-ii
1.929.531
1.987.417
2.026.008
2.064.598
777
W-4-16-iii
2.630.653
2.709.573
2.762.186
2.814.799
778
W-4-17-i
1.181.967
1.217.426
1.241.065
1.264.704
779
W-4-17-ii
1.929.531
1.987.417
2.026.008
2.064.598
780
W-4-17-iii
3.650.289
3.759.798
3.832.804
3.905.809
781
Z-4-10-i
REHABILITASI RINGAN
3.310.847
3.410.172
3.476.389
3.542.606
782
Z-4-10-ii
REHABILITASI SEDANG
4.394.671
4.526.512
4.614.405
4.702.298
783
Z-4-10-iii
REHABILITASI BERAT
6.243.050
6.430.341
6.555.202
6.680.063
784
Z-4-11-i
2.890.005
2.976.705
3.034.505
3.092.305

RINGAN
SEDANG
BERAT

- 407 No
Kode
INA-CBG
Deskripsi (INA-CBG)
785
Z-4-11-ii
786
Z-4-11-iii
787
Z-4-12-i
788
Z-4-12-ii
789
Z-4-12-iii
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.478.927
3.583.295
3.652.874
3.722.452
5.504.281
5.669.410
5.779.496
5.889.581
1.447.148
1.490.563
1.519.506
1.548.449
2.948.517
3.036.973
3.095.943
3.154.913
3.747.098
3.859.511
3.934.453
4.009.395

b. RawatJalan
No
Kode
INA-CBG
B-2-10-0
B-2-11-0
- 408 -
Deskripsi (INA-CBG)
LAPAROSKOPI
PANKREAS
LAPAROSKOPI
EMPEDU
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
800.166
824.171
840.174
856.178
1.037.940
1.069.079
1.089.837
1.110.596
1.930.187
1.988.093
2.026.696
2.065.300
1.595.112
1.642.966
1.674.868
1.706.770
1.332.579
1.372.556
1.399.208
1.425.859
467.208
481.224
490.568
499.913
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
1.041.813
1.073.067
1.093.903
1.114.739
B-3-12-0

214.058
220.480
224.761
229.042
C-3-10-0
583.921
601.438
613.117
624.795
10
C-3-11-0

KANDUNG KEMIH
923.492
951.197
969.667
988.137
11
C-3-12-0
209.354
215.634
219.822
224.009
12
C-3-13-0
203.297
209.396
213.462
217.528
13
C-3-14-0
1.730.670
1.782.590
1.817.203
1.851.817
14
C-3-15-0
1.586.228
1.633.815
1.665.539
1.697.264
15
C-3-16-0
359.718
370.510
377.704
384.899
16
C-3-17-0

LEHER
238.627
245.785
250.558
255.330
17
C-3-18-0
105.797
108.971
111.087
113.202
18
C-3-19-0

MYELOMA ATAU TESTIS
149.618
154.107
157.099
160.091
19
C-3-20-0
2.979.648
3.069.038
3.128.631
3.188.224
20
C-3-21-0
170.741
175.863
179.278
182.693
21
C-3-22-0
749.644
772.133
787.126
802.119
22
C-3-23-0
121.426
125.069
127.497
129.926
23
D-2-10-0

TULANG
1.028.737
1.059.599
1.080.174
1.100.749
24
D-2-11-0
PROSEDUR LIMPA
1.288.155
1.326.799
1.352.563
1.378.326
25
D-2-21-0
1.080.397
1.112.809
1.134.417
1.156.025
26
D-2-22-0
237.115
244.228
248.970
253.713
27
D-3-10-0
171.748
176.900
180.335
183.770
28
D-3-11-0
445.907
459.284
468.203
477.121
29
E-2-10-0
264.509
272.444
277.734
283.024
30
E-2-21-0
191.760
197.513
201.348
205.183
31
E-2-22-0
191.760
197.513
201.348
205.183

OVARIUM
GASTROINTESTINAL
GINJAL ATAU PROSTAT

TYMUS
TYMUS
TULANG
PEMBENTUK DARAH
DAN PARATIROID
THYROGLOSSAL
- 409 No
Kode
INA-CBG
32
E-3-10-0
33
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

ENDOKRIN
223.004
229.694
234.155
238.615
F-3-10-0
TERAPI SHOCK
311.084
320.416
326.638
332.860
34
F-5-10-0
381.178
392.614
400.237
407.861
35
F-5-11-0
TERAPI KELOMPOK
251.352
258.893
263.920
268.947
36
F-5-12-0
321.648
331.297
337.730
344.163
37
F-5-13-0
272.414
280.587
286.035
291.483
38
F-5-14-0
182.753
188.236
191.891
195.546
39
F-5-15-0
171.446
176.590
180.019
183.447
40
F-5-16-0
178.578
183.935
187.507
191.078
41
G-2-10-0
150.376
154.887
157.895
160.903
42
G-2-11-0
1.303.524
1.342.630
1.368.700
1.394.771
43
G-2-12-0

EKSTRAKRANIAL
1.889.128
1.945.801
1.983.584
2.021.366
44
G-2-13-0
463.445
477.348
486.617
495.886
45
G-2-21-0
845.246
870.603
887.508
904.413
46
G-2-22-0
767.132
790.146
805.489
820.832
47
G-2-31-0
1.265.835
1.303.810
1.329.127
1.354.444
48
G-2-32-0
648.866
668.332
681.309
694.287
49
G-3-10-0
257.539
265.265
270.416
275.567
50
G-3-11-0
342.993
353.282
360.142
367.002
51
G-3-12-0
561.999
578.859
590.099
601.339
52
G-3-13-0
562.063
578.925
590.167
601.408
53
H-2-21-0
737.625
759.754
774.506
789.259
54
H-2-22-0
191.760
197.513
201.348
205.183
55
H-2-23-0
191.760
197.513
201.348
205.183
56
H-2-31-0
1.221.814
1.258.469
1.282.905
1.307.341
57
H-2-32-0
127.162
130.977
133.520
136.064
58
H-2-33-0
191.760
197.513
201.348
205.183
59
H-2-34-0
548.136
564.580
575.542
586.505
60
H-2-35-0
180.623
186.042
189.654
193.267
61
H-2-36-0
974.961
1.004.210
1.023.710
1.043.209
62
H-2-37-0

1.037.889
1.069.026
1.089.784
1.110.542
63
H-3-10-0
361.110
371.943
379.165
386.387
64
H-3-11-0
189.904
195.601
199.399
203.197

AKUT
MENTAL
PROSEDUR KRANIOTOMI

MATA
MATA
MATA
MATA
MATA
- 410 No
Kode
INA-CBG
65
H-3-12-0
66
H-3-13-0
67
I-2-11-0
68
I-2-12-0
69
I-2-13-0
70
I-2-14-0
71
I-2-15-0
Deskripsi (INA-CBG)
MATA
TORASIK
ABDOMEN
PENGGANTIAN ALAT
DARAH VENA
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
198.269
204.217
208.183
212.148
192.507
198.283
202.133
205.983
2.220.020
2.286.620
2.331.021
2.375.421
1.560.916
1.607.744
1.638.962
1.670.180
1.983.831
2.043.345
2.083.022
2.122.699
3.510.958
3.616.286
3.686.505
3.756.725
211.142
217.476
221.699
225.922
2.217.614
2.284.142
2.328.495
2.372.847
731.084
753.016
767.638
782.259
72
I-2-16-0
73
I-2-17-0
74
I-2-21-0
1.711.683
1.763.033
1.797.267
1.831.500
75
I-2-22-0
1.611.849
1.660.204
1.692.441
1.724.678
76
I-2-23-0
329.860
339.756
346.353
352.950
77
I-2-31-0
2.565.433
2.642.396
2.693.705
2.745.014
78
I-2-32-0
3.354.681
3.455.321
3.522.415
3.589.508
79
I-2-41-0
2.249.355
2.316.835
2.361.822
2.406.809
80
I-2-42-0

LAIN
2.615.247
2.693.704
2.746.009
2.798.314
81
I-3-10-0
PROSEDUR RESUSITASI
331.982
341.942
348.581
355.221
82
I-3-11-0
175.220
180.476
183.981
187.485
83
I-3-12-0
1.018.310
1.048.859
1.069.225
1.089.591
84
I-3-13-0
334.452
344.486
351.175
357.864
85
I-3-14-0
214.373
220.804
225.091
229.379

PACU JANTUNG

KARDIOVASKULAR
PERNAFASAN
PENDEK
189.904
195.601
199.399
203.197
2.166.505
2.231.500
2.274.830
2.318.160
349.240
359.717
366.702
373.687
86
I-3-15-0
87
J-2-10-0
88
J-2-21-0
89
J-2-22-0
1.759.952
1.812.751
1.847.950
1.883.149
90
J-2-31-0
PROSEDUR
2.282.815
2.351.300
2.396.956
2.442.613
91
J-2-32-0
1.698.794
1.749.757
1.783.733
1.817.709
92
J-3-10-0
353.344
363.945
371.012
378.078
93
J-3-11-0

PADA DADA
998.488
1.028.443
1.048.413
1.068.382
94
J-3-12-0
385.764
397.337
405.052
412.767
95
J-3-13-0
567.748
584.780
596.135
607.490
96
J-3-14-0
602.726
620.808
632.863
644.917
- 411 No
Kode
INA-CBG
97
J-3-15-0
98
J-3-16-0
99
J-3-17-0
100
K-2-10-0
101
K-2-11-0
102
K-2-12-0

103
K-2-13-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
528.543
544.399
554.970
565.541
602.726
620.808
632.863
644.917
353.344
363.945
371.012
378.078
551.950
568.509
579.548
590.587
1.178.639
1.213.999
1.237.571
1.261.144
904.758
931.900
949.996
968.091
1.472.542
1.516.718
1.546.169
1.575.620
191.760
197.513
201.348
205.183
191.760
197.513
201.348
205.183
2.464.571
2.538.508
2.587.799
2.637.091
828.710
853.571
870.145
886.719
191.760
197.513
201.348
205.183

PERNAFASAN
KECIL

FEMORALIS
USUS BESAR
ATAS
ATAS
104
K-2-14-0
105
K-2-21-0
106
K-2-22-0
107
K-2-31-0
108
K-2-32-0
109
K-2-41-0
912.841
940.226
958.483
976.740
110
K-2-42-0

260.810
268.634
273.850
279.067
111
K-2-51-0
604.904
623.051
635.149
647.247
112
K-2-52-0
329.860
339.756
346.353
352.950
113
K-2-53-0
191.760
197.513
201.348
205.183
114
K-3-10-0

GASTROINTESTINAL
364.906
375.853
383.151
390.450
115
K-3-11-0
219.380
225.961
230.349
234.736
116
K-3-12-0
222.479
229.153
233.603
238.052
117
K-3-13-0
191.760
197.513
201.348
205.183
513.921
529.338
539.617
549.895
248.179
255.625
260.588
265.552
328.854
338.719
345.296
351.873
1.130.610
1.164.529
1.187.141
1.209.753
724.713
746.455
760.949
775.443
327.099
336.912
343.454
349.996
329.860
339.756
346.353
352.950

GASTROINTESTINAL
LUKA BAKAR
LUKA BAKAR
TANPA LUKA BAKAR
LUKA BAKAR
118
K-3-14-0
119
K-3-15-0
120
K-3-16-0
121
L-2-21-0
122
L-2-22-0
123
L-2-31-0
124
L-2-32-0
125
L-2-41-0
987.727
1.017.359
1.037.113
1.056.868
126
L-2-42-0

221.531
228.177
232.608
237.038
127
L-2-51-0
1.478.782
1.523.145
1.552.721
1.582.297
L-2-52-0

1.131.317
1.165.256
1.187.883
1.210.509
128
- 412 No
Kode
INA-CBG
129
L-2-53-0
130
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

191.760
197.513
201.348
205.183
L-3-10-0
260.810
268.634
273.850
279.067
131
L-3-11-0
253.264
260.862
265.928
270.993
132
L-3-12-0
192.885
198.672
202.529
206.387
133
M-2-10-0
1.512.902
1.558.289
1.588.547
1.618.805
134
M-2-21-0
1.354.908
1.395.555
1.422.653
1.449.752
135
M-2-22-0
329.860
339.756
346.353
352.950
136
M-2-31-0
PROSEDUR BUNION
822.971
847.660
864.119
880.578
137
M-2-32-0
260.810
268.634
273.850
279.067
138
M-2-41-0

TULANG
260.810
268.634
273.850
279.067
139
M-2-42-0
89.882
92.579
94.376
96.174
140
M-2-51-0
191.760
197.513
201.348
205.183
141
M-2-52-0
191.760
197.513
201.348
205.183
142
M-2-61-0
PROSEDUR ARTROSKOPI
939.915
968.113
986.911
1.005.709
143
M-2-62-0
191.760
197.513
201.348
205.183
945.000
973.350
992.250
1.011.150
1.288.785
1.327.448
1.353.224
1.379.000
191.760
197.513
201.348
205.183
951.462
980.006
999.035
1.018.064
918.201
945.747
964.111
982.475
1.369.234
1.410.311
1.437.695
1.465.080
994.660
1.024.500
1.044.393
1.064.287
191.760
197.513
201.348
205.183
191.760
197.513
201.348
205.183
547.320
563.739
574.686
585.632
303.455
312.559
318.628
324.697
686.241
706.828
720.553
734.278
144
M-2-63-0
145
M-2-64-0
146
M-2-65-0
147
M-2-71-0
148
M-2-72-0
149
M-2-81-0
150
M-2-82-0
151
M-2-83-0
152
M-2-84-0
153
M-3-10-0

DAN WAJAH
PAHA
PAHA

TULANG
WAJAH
WAJAH
BAWAH
BAWAH
BAHU
PERGELANGAN TANGAN
PERGELANGAN TANGAN
MUSKULOSKELETAL
SKELETAL
154
M-3-11-0
155
M-3-12-0
156
M-3-13-0
223.733
230.445
234.920
239.394
157
M-3-14-0

TERTUTUP
382.398
393.870
401.517
409.165
158
M-3-15-0
168.470
173.524
176.893
180.262
159
M-3-16-0

191.760
197.513
201.348
205.183
160
M-3-17-0
209.354
215.634
219.822
224.009
161
N-2-11-0
2.533.336
2.609.336
2.660.002
2.710.669
- 413 No
Kode
INA-CBG
162
N-2-12-0
163
N-2-21-0
164
N-2-22-0
165
N-2-23-0
166
N-2-24-0
167
N-2-31-0
168
N-2-32-0
169
N-2-41-0
170
N-2-42-0
171
N-3-10-0
172
N-3-11-0
173
N-3-12-0
174
N-3-13-0
175
N-3-14-0
176
N-3-15-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.465.510
1.509.475
1.538.785
1.568.095
1.457.785
1.501.518
1.530.674
1.559.830
329.860
339.756
346.353
352.950

URETER
329.860
339.756
346.353
352.950
1.065.997
1.097.977
1.119.297
1.140.617
897.397
924.319
942.267
960.214
329.860
339.756
346.353
352.950
329.860
339.756
346.353
352.950
557.857
574.592
585.749
596.907
329.860
339.756
346.353
352.950
382.190
393.656
401.300
408.943
295.335
304.195
310.102
316.008
329.860
339.756
346.353
352.950
283.827
292.341
298.018
303.695
727.803
749.637
764.193
778.749
121.512
125.157
127.587
130.018
669.197
689.273
702.657
716.041
243.677
250.988
255.861
260.735
135.425
139.488
142.196
144.905
180.623
186.042
189.654
193.267


DAN URETHRA
DAN URETHRA
TRANSURETHRA
TRANSURETHRA
SALURAN KEMIH
KEMIH
KEMIH
PROSEDUR DIALISIS
CAESAR
VAGINAL/JALAN LAHIR
177
O-7-10-0
178
O-7-11-0
179
O-7-12-0
180
O-7-13-0
181
P-9-10-0
182
P-9-11-0
180.623
186.042
189.654
193.267
183
P-9-12-0
180.623
186.042
189.654
193.267
184
P-9-13-0
180.623
186.042
189.654
193.267
185
P-9-14-0
180.623
186.042
189.654
193.267
186
P-9-15-0
115.133
118.587
120.890
123.192
187
P-9-16-0
180.623
186.042
189.654
193.267
188
P-9-17-0
179.846
185.242
188.839
192.436
189
Q-5-10-0
235.410
242.472
247.180
251.888
190
Q-5-11-0
176.433
181.726
185.255
188.783
191
Q-5-12-0
GIGI
155.503
160.169
163.279
166.389
192
Q-5-13-0
MEDICAL CHECK-UP
118.176
121.721
124.085
126.448
193
Q-5-14-0
130.032
133.933
136.534
139.134

ASPIRASI
- 414 No
Kode
INA-CBG
194
Q-5-15-0
195
Q-5-16-0
VAKSINASI
196
Q-5-17-0
PASANG INFUS
197
Q-5-18-0
198
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
89.423
92.106
93.894
95.683
101.069
104.101
106.122
108.143
87.422
90.044
91.793
93.541
164.555
169.492
172.783
176.074
Q-5-19-0
183.963
189.481
193.161
196.840
199
Q-5-20-0
ABORSI MENGANCAM
123.304
127.003
129.469
131.935
200
Q-5-21-0
ABORSI
121.625
125.273
127.706
130.138
201
Q-5-22-0
130.032
133.933
136.534
139.134
202
Q-5-23-0
159.194
163.969
167.153
170.337
203
Q-5-24-0
108.727
111.989
114.163
116.338
204
Q-5-25-0
169.557
174.644
178.035
181.426
205
Q-5-26-0
BRONKIAL AKUT
442.228
455.494
464.339
473.184
206
Q-5-27-0
170.793
175.917
179.333
182.749
207
Q-5-28-0
138.594
142.752
145.524
148.296
208
Q-5-29-0

JANTUNG LAIN-LAIN
392.384
404.155
412.003
419.850
209
Q-5-30-0
454.730
468.372
477.467
486.561
210
Q-5-31-0
FRAKTUR
162.230
167.096
170.341
173.586
211
Q-5-32-0
SALURAN KEMIH AKUT
187.898
193.535
197.293
201.051
212
Q-5-33-0
HEMATOLOGI AKUT
196.729
202.631
206.565
210.500
213
Q-5-34-0
INFEKSI VIRUS HIV
279.467
287.851
293.441
299.030
214
Q-5-35-0
INFEKSI AKUT
316.908
326.416
332.754
339.092
215
Q-5-36-0
369.060
380.132
387.513
394.894
216
Q-5-37-0

SHOCK
188.240
193.887
197.652
201.416
217
Q-5-38-0
PARU AKUT
462.546
476.422
485.673
494.924
218
Q-5-39-0
160.637
165.456
168.668
171.881
219
Q-5-40-0
157.610
162.339
165.491
168.643
220
Q-5-41-0
218.189
224.735
229.098
233.462
221
Q-5-42-0
171.069
176.201
179.622
183.044
222
Q-5-43-0
246.349
253.739
258.666
263.593
223
Q-5-44-0
201.055
207.087
211.108
215.129
224
T-2-10-0

TERAPI DETOKSIKASI
104.284
107.412
109.498
111.584
225
U-2-10-0
1.391.785
1.433.539
1.461.375
1.489.210
226
U-2-11-0

LEHER
1.654.292
1.703.920
1.737.006
1.770.092
227
U-2-12-0
182.015
187.476
191.116
194.756
- 415 No
Kode
INA-CBG
228
U-2-13-0
229
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
238.627
245.785
250.558
255.330
U-2-14-0
443.260
456.558
465.423
474.288
230
U-2-15-0
251.851
259.406
264.443
269.480
231
U-2-21-0
293.367
302.168
308.035
313.902
232
U-2-22-0
566.808
583.812
595.148
606.484
233
U-2-23-0
742.701
764.982
779.836
794.690
234
U-2-24-0
625.936
644.714
657.233
669.751
235
U-2-25-0
238.627
245.785
250.558
255.330
236
U-2-31-0
191.760
197.513
201.348
205.183
237
U-2-32-0
238.627
245.785
250.558
255.330
238
U-3-10-0
228.140
234.984
239.546
244.109
239
U-3-11-0
242.213
249.479
254.324
259.168
240
U-3-12-0
107.106
110.319
112.462
114.604
241
U-3-13-0
235.428
242.491
247.199
251.908
242
U-3-14-0
216.310
222.799
227.125
231.451
243
U-3-15-0
188.641
194.301
198.073
201.846
244
U-3-16-0
PROSEDUR PADA GIGI
212.753
219.136
223.391
227.646
245
V-2-10-0

PROSTAT
2.075.654
2.137.923
2.179.436
2.220.949
246
V-2-11-0
PROSEDUR PADA PENIS
234.081
241.103
245.785
250.467
247
V-2-12-0
746.986
769.395
784.335
799.275
248
V-2-13-0
329.860
339.756
346.353
352.950
249
V-2-14-0
329.860
339.756
346.353
352.950
250
V-2-15-0
SIRKUMSISI/SUNAT
180.623
186.042
189.654
193.267
251
V-3-10-0
376.702
388.003
395.537
403.071
796.919
820.827
836.765
852.704
460.083
473.885
483.087
492.288
168.470
173.524
176.893
180.262
430.545
443.462
452.073
460.684
796.919
820.827
836.765
852.704
127.812
131.646
134.202
136.758
1.602.020
1.650.081
1.682.121
1.714.162
252
V-3-11-0
253
V-3-12-0
254
W-2-10-0
255
W-2-11-0
256
W-2-12-0
257
W-2-13-0
258
W-2-21-0

(RHINOPLASTY)

TENGGOROKAN
RONGGA HIDUNG
TENGGOROKAN

SKROTUM
SKROTUM
TRANSURETHRAL

PROSEDUR ABORSI
RAHIM & LEHER RAHIM
TERHALANG/TERGANGGU
TERHALANG/TERGANGGU
PANGGUL TERBUKA
- 416 No
Kode
INA-CBG
259
W-2-22-0
260
W-2-23-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

PANGGUL TERBUKA
168.470
173.524
176.893
180.262
562.191
579.057
590.301
601.545
1.845.502
1.900.867
1.937.777
1.974.688
1.294.335
1.333.165
1.359.051
1.384.938

JALAN LAHIR
261
W-2-31-0
262
W-2-32-0
263
W-2-33-0
550.109
566.613
577.615
588.617
264
W-2-34-0
187.102
192.715
196.457
200.199
265
W-3-10-0
454.730
468.372
477.466
486.561
266
W-3-11-0
363.498
374.403
381.673
388.943
267
W-3-12-0
168.470
173.524
176.893
180.262
268
Z-3-10-0
1.907.300
1.964.519
2.002.665
2.040.811
269
Z-3-11-0

EMPEDU
1.457.785
1.501.518
1.530.674
1.559.830
270
Z-3-12-0
243.415
250.717
255.586
260.454
271
Z-3-13-0

LAIN-LAIN
1.485.384
1.529.945
1.559.653
1.589.361
272
Z-3-14-0
DIAGNOSTIK TIDUR
293.706
302.518
308.392
314.266
273
Z-3-15-0
191.760
197.513
201.348
205.183
274
Z-3-16-0

(MRI)
615.491
633.956
646.265
658.575
275
Z-3-17-0
PENGOBATAN NUKLIR
258.396
266.148
271.316
276.484
276
Z-3-18-0
CT-SCAN KEPALA
248.960
256.429
261.408
266.387
277
Z-3-19-0
CT SCAN LAIN-LAIN
259.119
266.892
272.075
277.257
278
Z-3-20-0
176.233
181.520
185.045
188.569
279
Z-3-21-0
168.470
173.524
176.893
180.262
280
Z-3-22-0
189.934
195.632
199.431
203.230
281
Z-3-23-0
197.833
203.768
207.725
211.681
282
Z-3-24-0
388.703
400.364
408.138
415.912
283
Z-3-25-0
173.128
178.321
181.784
185.247
284
Z-3-26-0
195.668
201.538
205.452
209.365
285
Z-3-27-0
PERAWATAN LUKA
186.810
192.415
196.151
199.887
286
Z-3-28-0
IMAGING PAYUDARA
191.760
197.513
201.348
205.183
287
Z-3-29-0
IMAGING LAIN-LAIN
552.686
569.267
580.321
591.375
288
Z-3-30-0
FOTOTERAPI
93.273
96.071
97.937
99.802
- 417 III.
TARIF INA-CBG RUMAH SAKIT UMUM DAN KHUSUS KELAS B

NON PENDIDIKAN TAHUN 2012
A. RUMAH SAKIT UMUM KELAS B NON PENDIDIKAN
1. RawatInap
No
Kode
INA-CBG
A-4-10-i
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
SEPTIKEMIA RINGAN
1.849.284
1.865.927
1.877.023
1.888.119
A-4-10-ii
SEPTIKEMIA SEDANG
3.160.592
3.189.037
3.208.001
3.226.964
A-4-10-iii
SEPTIKEMIA BERAT
3.743.117
3.776.805
3.799.264
3.821.723
A-4-11-i
4.962.144
5.006.803
5.036.576
5.066.349
A-4-11-ii

SEDANG
7.665.939
7.734.933
7.780.928
7.826.924
A-4-11-iii
12.539.801
12.652.660
12.727.898
12.803.137
A-4-12-i
DEMAM RINGAN
1.447.148
1.460.173
1.468.856
1.477.538
A-4-12-ii
DEMAM SEDANG
2.791.923
2.817.050
2.833.802
2.850.553
A-4-12-iii
DEMAM BERAT
3.195.151
3.223.907
3.243.078
3.262.249
10
A-4-13-i
1.808.935
1.825.216
1.836.069
1.846.923
11
A-4-13-ii
2.170.723
2.190.259
2.203.283
2.216.308
12
A-4-13-iii
2.638.257
2.662.001
2.677.830
2.693.660
1.702.604
1.717.928
1.728.143
1.738.359
2.776.944
2.801.937
2.818.598
2.835.260
3.098.989
3.126.880
3.145.473
3.164.067

LAIN-LAIN RINGAN
LAIN-LAIN SEDANG
LAIN-LAIN BERAT
13
A-4-14-i
14
A-4-14-ii
15
A-4-14-iii
16
A-4-15-i
INFEKSI HIV RINGAN
2.276.052
2.296.536
2.310.193
2.323.849
17
A-4-15-ii
INFEKSI HIV SEDANG
3.256.084
3.285.389
3.304.925
3.324.462
18
A-4-15-iii
INFEKSI HIV BERAT
6.091.222
6.146.043
6.182.591
6.219.138
19
B-1-01-i
24.308.136
24.526.909
24.672.758
24.818.607
20
B-1-01-ii
26.818.373
27.059.738
27.220.648
27.381.558
21
B-1-01-iii
47.044.944
47.468.349
47.750.618
48.032.888
22
B-1-10-i
3.151.467
3.179.831
3.198.739
3.217.648
23
B-1-10-ii
8.031.457
8.103.740
8.151.929
8.200.117
24
B-1-10-iii
18.616.547
18.784.096
18.895.795
19.007.495
2.869.056
2.894.878
2.912.092
2.929.307
7.201.602
7.266.417
7.309.626
7.352.836
9.029.022
9.110.283
9.164.457
9.218.631
6.119.801
6.174.879
6.211.598
6.248.317
25
B-1-11-i
26
B-1-11-ii
27
B-1-11-iii
28
B-1-12-i

(RINGAN)
(SEDANG)
(BERAT)
LAPAROSKOPIK RINGAN
- 418 No
Kode
INA-CBG
29
B-1-12-ii
30
B-1-12-iii
31
B-1-13-i
32
B-1-13-ii
33
B-1-13-iii
34
B-1-14-i
35
B-1-14-ii
36
B-1-14-iii
37
B-4-10-i
38
B-4-10-ii
39
B-4-10-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
13.116.230
13.234.276
13.312.973
13.391.671
15.594.196
15.734.543
15.828.108
15.921.674
4.010.169
4.046.261
4.070.322
4.094.383
6.531.984
6.590.772
6.629.963
6.669.155
9.629.977
9.716.647
9.774.426
9.832.206
5.445.528
5.494.537
5.527.211
5.559.884
6.056.526
6.111.034
6.147.374
6.183.713
9.474.714
9.559.987
9.616.835
9.673.683
1.523.576
1.537.288
1.546.429
1.555.571
2.207.117
2.226.981
2.240.224
2.253.467
3.720.079
3.753.560
3.775.880
3.798.201
3.678.483
3.711.589
3.733.660
3.755.731
5.592.213
5.642.543
5.676.096
5.709.649
6.023.007
6.077.214
6.113.352
6.149.490
3.227.617
3.256.665
3.276.031
3.295.397
4.575.966
4.617.150
4.644.606
4.672.062
8.696.517
8.774.786
8.826.965
8.879.144
2.170.723
2.190.259
2.203.283
2.216.308
3.160.190
3.188.632
3.207.593
3.226.554
5.222.235
5.269.235
5.300.568
5.331.902
2.795.105
2.820.261
2.837.032
2.853.803
3.140.928
3.169.196
3.188.042
3.206.887
3.995.559
4.031.519
4.055.493
4.079.466

LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT
LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT

PANCREAS RINGAN
PANCREAS SEDANG
PANCREAS BERAT
(RINGAN)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT
40
B-4-11-i
41
B-4-11-ii
42
B-4-11-iii
43
B-4-12-i
44
B-4-12-ii
45
B-4-12-iii
46
B-4-13-i
47
B-4-13-ii
48
B-4-13-iii
49
B-4-14-i
50
B-4-14-ii
51
B-4-14-iii
52
C-4-10-i
2.843.339
2.868.929
2.885.989
2.903.049
53
C-4-10-ii
5.524.309
5.574.027
5.607.173
5.640.319
54
C-4-10-iii
LEUKEMIA AKUT BERAT
8.152.526
8.225.899
8.274.814
8.323.729
55
C-4-11-i
2.860.389
2.886.132
2.903.295
2.920.457
56
C-4-11-ii
3.277.489
3.306.986
3.326.651
3.346.316
57
C-4-11-iii
6.618.769
6.678.337
6.718.050
6.757.763
58
C-4-12-i
RADIOTERAPI RINGAN
1.447.148
1.460.173
1.468.856
1.477.538
59
C-4-12-ii
RADIOTERAPI SEDANG
5.359.475
5.407.710
5.439.867
5.472.023
60
C-4-12-iii
RADIOTERAPI BERAT
10.880.807
10.978.734
11.044.019
11.109.304
- 419 No
Kode
INA-CBG
61
C-4-13-i
62
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
KEMOTERAPI RINGAN
1.447.148
1.460.173
1.468.856
1.477.538
C-4-13-ii
KEMOTERAPI SEDANG
2.894.297
2.920.345
2.937.711
2.955.077
63
C-4-13-iii
KEMOTERAPI BERAT
3.786.973
3.821.056
3.843.778
3.866.500
64
C-4-14-i
2.524.171
2.546.888
2.562.033
2.577.178
65
C-4-14-ii
3.688.480
3.721.676
3.743.807
3.765.938
66
C-4-14-iii
5.622.981
5.673.588
5.707.326
5.741.063
67
D-1-10-i
15.554.414
15.694.404
15.787.730
15.881.057
68
D-1-10-ii
23.690.566
23.903.781
24.045.924
24.188.068
69
D-1-10-iii
32.107.190
32.396.155
32.588.798
32.781.441
70
D-1-11-i
4.257.530
4.295.848
4.321.393
4.346.938
71
D-1-11-ii
9.747.175
9.834.900
9.893.383
9.951.866
72
D-1-11-iii
15.277.961
15.415.462
15.507.130
15.598.798
73
D-1-20-i
3.898.870
3.933.960
3.957.353
3.980.746
74
D-1-20-ii
10.737.903
10.834.544
10.898.971
10.963.399
75
D-1-20-iii
17.057.557
17.211.075
17.313.420
17.415.766
76
D-4-10-i
1.677.051
1.692.145
1.702.207
1.712.269
77
D-4-10-ii
2.806.823
2.832.084
2.848.925
2.865.766
78
D-4-10-iii
3.927.277
3.962.622
3.986.186
4.009.749
79
D-4-11-i
1.808.935
1.825.216
1.836.069
1.846.923
80
D-4-11-ii
4.096.459
4.133.328
4.157.906
4.182.485
81
D-4-11-iii
6.205.566
6.261.416
6.298.649
6.335.883
82
D-4-12-i
1.874.305
1.891.174
1.902.419
1.913.665
83
D-4-12-ii
2.599.845
2.623.244
2.638.843
2.654.442
84
D-4-12-iii
3.992.063
4.027.992
4.051.944
4.075.897
85
D-4-13-i
1.447.148
1.460.173
1.468.856
1.477.538
86
D-4-13-ii
2.170.723
2.190.259
2.203.283
2.216.308
87
D-4-13-iii
2.999.776
3.026.774
3.044.773
3.062.771
88
D-4-14-i
1.808.935
1.825.216
1.836.069
1.846.923
89
D-4-14-ii
4.070.967
4.107.605
4.132.031
4.156.457
90
D-4-14-iii
4.856.100
4.899.805
4.928.941
4.958.078
91
E-1-01-i
4.666.116
4.708.111
4.736.108
4.764.105
92
E-1-01-ii
6.112.168
6.167.178
6.203.851
6.240.524
93
E-1-01-iii
12.115.335
12.224.373
12.297.065
12.369.757

RINGAN
SEDANG
BERAT
TULANG RINGAN
TULANG SEDANG
TULANG BERAT


RINGAN
SEDANG
BERAT
- 420 No
Kode
INA-CBG
94
E-1-10-i
95
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.570.279
3.602.412
3.623.833
3.645.255
E-1-10-ii
4.333.481
4.372.482
4.398.483
4.424.484
96
E-1-10-iii
9.133.702
9.215.905
9.270.707
9.325.510
97
E-1-20-i
5.505.836
5.555.388
5.588.423
5.621.458
98
E-1-20-ii
7.374.177
7.440.545
7.484.790
7.529.035
99
E-1-20-iii
16.339.093
16.486.145
16.584.180
16.682.214
100
E-4-10-i
2.259.199
2.279.531
2.293.087
2.306.642
101
E-4-10-ii
3.460.527
3.491.672
3.512.435
3.533.198
102
E-4-10-iii
5.869.671
5.922.498
5.957.716
5.992.934
103
E-4-11-i
2.076.031
2.094.716
2.107.172
2.119.628
104
E-4-11-ii
3.927.495
3.962.842
3.986.407
4.009.972
105
E-4-11-iii
6.476.620
6.534.909
6.573.769
6.612.629
106
E-4-12-i
1.989.829
2.007.737
2.019.676
2.031.615
107
E-4-12-ii
3.256.084
3.285.389
3.304.925
3.324.462
108
E-4-12-iii
5.231.286
5.278.367
5.309.755
5.341.143
2.616.513
2.640.062
2.655.761
2.671.460
4.492.571
4.533.004
4.559.960
4.586.915
7.773.282
7.843.242
7.889.882
7.936.521

RINGAN
SEDANG
BERAT

RINGAN
SEDANG
BERAT
109
E-4-13-i
110
E-4-13-ii
111
E-4-13-iii
112
F-4-10-i
SCHIZOFRENIA RINGAN
3.199.182
3.227.975
3.247.170
3.266.365
113
F-4-10-ii
SCHIZOFRENIA SEDANG
3.552.794
3.584.770
3.606.086
3.627.403
114
F-4-10-iii
SCHIZOFRENIA BERAT
5.259.991
5.307.330
5.338.890
5.370.450
115
F-4-11-i
2.948.871
2.975.411
2.993.104
3.010.797
116
F-4-11-ii
3.435.715
3.466.636
3.487.250
3.507.865
117
F-4-11-iii
DEPRESI MAYOR BERAT
4.405.842
4.445.494
4.471.929
4.498.364
1.440.036
1.452.997
1.461.637
1.470.277
1.903.479
1.920.611
1.932.031
1.943.452
3.739.500
3.773.156
3.795.593
3.818.030

IMPULSE RINGAN
IMPULSE SEDANG
IMPULSE BERAT
118
F-4-12-i
119
F-4-12-ii
120
F-4-12-iii
121
F-4-13-i
2.383.136
2.404.584
2.418.883
2.433.182
122
F-4-13-ii
3.155.884
3.184.287
3.203.222
3.222.158
123
F-4-13-iii
4.069.110
4.105.732
4.130.146
4.154.561
124
F-4-14-i
DEPRESI RINGAN
1.668.195
1.683.209
1.693.218
1.703.227
125
F-4-14-ii
DEPRESI SEDANG
2.139.798
2.159.057
2.171.895
2.184.734
126
F-4-14-iii
DEPRESI BERAT
2.879.194
2.905.107
2.922.382
2.939.657
- 421 No
Kode
INA-CBG
127
F-4-15-i
128
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.983.389
2.001.239
2.013.140
2.025.040
F-4-15-ii
2.792.201
2.817.331
2.834.084
2.850.837
129
F-4-15-iii
3.487.383
3.518.769
3.539.693
3.560.618
130
F-4-16-i
4.271.832
4.310.278
4.335.909
4.361.540
131
F-4-16-ii
4.965.897
5.010.590
5.040.386
5.070.181
132
F-4-16-iii
6.628.644
6.688.302
6.728.074
6.767.846
133
F-4-17-i
740.647
747.312
751.756
756.200
134
F-4-17-ii
2.170.765
2.190.302
2.203.326
2.216.351
135
F-4-17-iii
2.316.046
2.336.891
2.350.787
2.364.683
136
F-4-18-i
3.702.680
3.736.004
3.758.220
3.780.436
137
F-4-18-ii
4.073.993
4.110.659
4.135.103
4.159.547
138
F-4-18-iii
6.280.416
6.336.940
6.374.622
6.412.305
139
F-4-19-i
2.839.606
2.865.162
2.882.200
2.899.238
140
F-4-19-ii
3.636.189
3.668.914
3.690.731
3.712.549
141
F-4-19-iii
4.527.103
4.567.847
4.595.010
4.622.173
142
G-1-01-i
6.779.115
6.840.127
6.880.802
6.921.476
143
G-1-01-ii
11.474.469
11.577.739
11.646.586
11.715.433
144
G-1-01-iii
22.213.291
22.413.210
22.546.490
22.679.770
145
G-1-10-i
4.505.284
4.545.832
4.572.864
4.599.895
146
G-1-10-ii
6.360.341
6.417.584
6.455.747
6.493.909
147
G-1-10-iii
7.538.363
7.606.208
7.651.439
7.696.669
148
G-1-11-i
5.196.980
5.243.753
5.274.935
5.306.117
149
G-1-11-ii
10.672.390
10.768.441
10.832.476
10.896.510
150
G-1-11-iii
19.494.351
19.669.800
19.786.766
19.903.732
151
G-1-12-i
4.041.719
4.078.095
4.102.345
4.126.595
152
G-1-12-ii
8.772.458
8.851.410
8.904.045
8.956.680
153
G-1-12-iii
12.970.601
13.087.337
13.165.160
13.242.984
154
G-1-13-i
800.429
807.633
812.436
817.238
155
G-1-13-ii
2.149.865
2.169.213
2.182.112
2.195.012
156
G-1-13-iii
4.851.000
4.894.659
4.923.765
4.952.871
157
G-1-20-i
5.092.910
5.138.746
5.169.304
5.199.861
158
G-1-20-ii
6.880.688
6.942.615
6.983.899
7.025.183
159
G-1-20-iii
16.846.556
16.998.175
17.099.254
17.200.334

RINGAN
SEDANG
BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

RINGAN
SEDANG
BERAT
- 422 No
Kode
INA-CBG
160
G-1-30-i
161
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
6.495.548
6.554.008
6.592.981
6.631.955
G-1-30-ii
16.954.004
17.106.590
17.208.314
17.310.038
162
G-1-30-iii
21.825.042
22.021.468
22.152.418
22.283.368
163
G-4-10-i
2.170.723
2.190.259
2.203.283
2.216.308
164
G-4-10-ii
2.968.589
2.995.306
3.013.118
3.030.929
165
G-4-10-iii
5.204.164
5.251.001
5.282.226
5.313.451
166
G-4-11-i
4.817.533
4.860.891
4.889.796
4.918.701
167
G-4-11-ii
5.588.338
5.638.634
5.672.164
5.705.694
168
G-4-11-iii
8.189.806
8.263.515
8.312.653
8.361.792
169
G-4-12-i
3.603.091
3.635.519
3.657.137
3.678.756
170
G-4-12-ii
4.539.894
4.580.753
4.607.993
4.635.232
171
G-4-12-iii
6.593.656
6.652.999
6.692.561
6.732.123
172
G-4-13-i
2.004.736
2.022.778
2.034.807
2.046.835
173
G-4-13-ii
2.785.456
2.810.525
2.827.238
2.843.951
174
G-4-13-iii
3.251.377
3.280.639
3.300.147
3.319.655
175
G-4-14-i
3.666.363
3.699.360
3.721.358
3.743.356
176
G-4-14-ii
6.032.404
6.086.695
6.122.890
6.159.084
177
G-4-14-iii
7.552.707
7.620.681
7.665.997
7.711.314
178
G-4-15-i
2.427.876
2.449.727
2.464.294
2.478.861
179
G-4-15-ii
3.014.993
3.042.128
3.060.218
3.078.308
180
G-4-15-iii
4.443.013
4.483.000
4.509.658
4.536.316
181
G-4-16-i
2.026.106
2.044.341
2.056.498
2.068.655
182
G-4-16-ii
2.931.475
2.957.858
2.975.447
2.993.035
183
G-4-16-iii
5.157.987
5.204.409
5.235.356
5.266.304
184
G-4-17-i
3.477.270
3.508.565
3.529.429
3.550.293
185
G-4-17-ii
4.315.445
4.354.284
4.380.177
4.406.069
186
G-4-17-iii
7.232.721
7.297.816
7.341.212
7.384.609
187
G-4-18-i
2.189.064
2.208.766
2.221.900
2.235.035
188
G-4-18-ii
4.186.551
4.224.230
4.249.349
4.274.468
189
G-4-18-iii
4.435.224
4.475.141
4.501.753
4.528.364

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
DEGENERATIF RINGAN
DEGENERATIF SEDANG
DEGENERATIF BERAT
RINGAN
SEDANG
BERAT
TRAUMATIK RINGAN
TRAUMATIK SEDANG
TRAUMATIK BERAT
DENGAN INFARK BERAT
TANPA INFARK RINGAN
TANPA INFARK SEDANG
TANPA INFARK BERAT

PERIFER RINGAN
PERIFER SEDANG
PERIFER BERAT
PERSARAFAN RINGAN
PERSARAFAN SEDANG
PERSARAFAN BERAT
- 423 No
Kode
INA-CBG
190
G-4-19-i
191
G-4-19-ii
192
G-4-19-iii
193
G-4-20-i
194
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.431.904
2.453.791
2.468.382
2.482.974
4.307.716
4.346.486
4.372.332
4.398.179
6.128.398
6.183.553
6.220.324
6.257.094
1.428.139
1.440.993
1.449.562
1.458.130
G-4-20-ii
1.965.322
1.983.010
1.994.802
2.006.594
195
G-4-20-iii
3.246.159
3.275.374
3.294.851
3.314.328
196
G-4-21-i
1.973.668
1.991.431
2.003.273
2.015.115
197
G-4-21-ii
2.743.399
2.768.090
2.784.550
2.801.010
198
G-4-21-iii
4.815.751
4.859.092
4.887.987
4.916.881
199
G-4-22-i
1.447.148
1.460.173
1.468.856
1.477.538
200
G-4-22-ii
1.808.935
1.825.216
1.836.069
1.846.923
201
G-4-22-iii
2.075.322
2.094.000
2.106.452
2.118.904
202
G-4-23-i
1.777.468
1.793.465
1.804.130
1.814.795
203
G-4-23-ii
1.851.617
1.868.281
1.879.391
1.890.501
204
G-4-23-iii
2.636.247
2.659.973
2.675.791
2.691.608
205
G-4-24-i
1.490.239
1.503.651
1.512.593
1.521.534
206
G-4-24-ii
2.160.265
2.179.707
2.192.669
2.205.630
207
G-4-24-iii
TRAUMA KEPALA BERAT
4.172.670
4.210.224
4.235.260
4.260.296
208
G-4-25-i
GEGAR OTAK RINGAN
1.447.148
1.460.173
1.468.856
1.477.538
209
G-4-25-ii
GEGAR OTAK SEDANG
1.808.935
1.825.216
1.836.069
1.846.923
210
G-4-25-iii
GEGAR OTAK BERAT
2.258.800
2.279.129
2.292.682
2.306.234
211
G-4-26-i
2.933.472
2.959.873
2.977.474
2.995.075
212
G-4-26-ii
3.326.655
3.356.595
3.376.555
3.396.515
213
G-4-26-iii
4.882.877
4.926.823
4.956.120
4.985.417
214
H-1-20-i
2.797.973
2.823.155
2.839.942
2.856.730
215
H-1-20-ii
5.102.420
5.148.342
5.178.956
5.209.571
216
H-1-20-iii
6.938.973
7.001.423
7.043.057
7.084.691
217
H-1-30-i
2.739.482
2.764.137
2.780.574
2.797.011
218
H-1-30-ii
3.123.009
3.151.116
3.169.854
3.188.593
219
H-1-30-iii
5.210.628
5.257.524
5.288.788
5.320.051
220
H-4-10-i
2.481.512
2.503.845
2.518.734
2.533.624
221
H-4-10-ii
4.039.957
4.076.317
4.100.557
4.124.797
222
H-4-10-iii
6.343.243
6.400.332
6.438.391
6.476.451

SEDANG

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)

RINGAN
SEDANG
- 424 No
Kode
INA-CBG
223
H-4-11-i
224
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.988.093
2.005.986
2.017.914
2.029.843
H-4-11-ii
2.194.473
2.214.223
2.227.390
2.240.557
225
H-4-11-iii
2.900.463
2.926.567
2.943.970
2.961.373
226
H-4-12-i
2.758.399
2.783.225
2.799.775
2.816.326
227
H-4-12-ii
3.736.432
3.770.060
3.792.479
3.814.898
228
H-4-12-iii
6.233.983
6.290.089
6.327.492
6.364.896
31.534.817
31.818.630
32.007.839
32.197.048
32.228.747
32.518.806
32.712.178
32.905.551
50.872.459
51.330.311
51.635.546
51.940.781
17.495.335
17.652.793
17.757.765
17.862.737
22.568.982
22.772.102
22.907.516
23.042.930
27.817.582
28.067.940
28.234.846
28.401.751
10.666.857
10.762.858
10.826.859
10.890.861
14.620.763
14.752.350
14.840.075
14.927.799
21.443.786
21.636.780
21.765.443
21.894.106
17.504.156
17.661.694
17.766.718
17.871.743
22.484.399
22.686.759
22.821.665
22.956.572
47.932.071
48.363.460
48.651.052
48.938.645
23.155.590
23.363.990
23.502.924
23.641.857
27.786.708
28.036.788
28.203.508
28.370.229
38.234.335
38.578.444
38.807.850
39.037.256

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
KATETERISASI RINGAN
KATETERISASI SEDANG
KATETERISASI BERAT
RINGAN
SEDANG
BERAT
229
I-1-01-i
230
I-1-01-ii
231
I-1-01-iii
232
I-1-02-i
233
I-1-02-ii
234
I-1-02-iii
235
I-1-03-i
236
I-1-03-ii
237
I-1-03-iii
238
I-1-04-i
239
I-1-04-ii
240
I-1-04-iii
241
I-1-05-i
242
I-1-05-ii
243
I-1-05-iii
244
I-1-06-i
14.535.492
14.666.312
14.753.525
14.840.738
245
I-1-06-ii
19.020.698
19.191.884
19.306.008
19.420.133
246
I-1-06-iii
20.995.738
21.184.700
21.310.674
21.436.649
247
I-1-07-i
19.115.273
19.287.310
19.402.002
19.516.694
248
I-1-07-ii
23.582.572
23.794.816
23.936.311
24.077.806
249
I-1-07-iii
25.728.433
25.959.989
26.114.360
26.268.730
250
I-1-11-i
3.636.191
3.668.917
3.690.734
3.712.551
251
I-1-11-ii
4.043.081
4.079.469
4.103.727
4.127.986
252
I-1-11-iii
5.380.108
5.428.529
5.460.810
5.493.091

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
RINGAN
SEDANG
BERAT
- 425 No
Kode
INA-CBG
253
I-1-12-i
254
I-1-12-ii
255
I-1-12-iii
256
I-1-13-i
257
I-1-13-ii
258
I-1-13-iii
259
I-1-14-i
260
I-1-14-ii
261
I-1-14-iii
262
I-1-15-i
263
I-1-15-ii
264
I-1-15-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
9.294.646
9.378.298
9.434.066
9.489.834
12.537.836
12.650.676
12.725.903
12.801.130
17.121.717
17.275.812
17.378.543
17.481.273
5.677.779
5.728.879
5.762.946
5.797.012
6.384.165
6.441.623
6.479.928
6.518.233
13.903.315
14.028.445
14.111.865
14.195.285
18.009.903
18.171.992
18.280.052
18.388.111
22.383.737
22.585.191
22.719.493
22.853.795
29.330.414
29.594.388
29.770.370
29.946.353
5.731.286
5.782.867
5.817.255
5.851.643
10.500.110
10.594.611
10.657.612
10.720.612
18.118.519
18.281.585
18.390.296
18.499.007
7.718.530
7.787.997
7.834.308
7.880.619
20.068.178
20.248.792
20.369.201
20.489.610
23.148.151
23.356.484
23.495.373
23.634.262
3.296.471
3.326.139
3.345.918
3.365.696
6.828.186
6.889.639
6.930.608
6.971.577
39.585.666
39.941.937
40.179.451
40.416.965
5.208.327
5.255.202
5.286.452
5.317.702
8.772.458
8.851.410
8.904.045
8.956.680
16.909.153
17.061.335
17.162.790
17.264.245
8.756.712
8.835.523
8.888.063
8.940.603
18.215.731
18.379.672
18.488.967
18.598.261
28.227.767
28.481.817
28.651.183
28.820.550
15.681.779
15.822.915
15.917.005
16.011.096
20.214.403
20.396.333
20.517.619
20.638.906
24.311.482
24.530.285
24.676.154
24.822.023

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

DARAH VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
265
I-1-16-i
266
I-1-16-ii
267
I-1-16-iii
268
I-1-17-i
269
I-1-17-ii
270
I-1-17-iii
271
I-1-20-i
272
I-1-20-ii
273
I-1-20-iii
274
I-1-30-i
275
I-1-30-ii
276
I-1-30-iii
277
I-1-40-i
278
I-1-40-ii
279
I-1-40-iii
280
I-4-10-i
4.560.717
4.601.763
4.629.128
4.656.492
281
I-4-10-ii
7.201.454
7.266.267
7.309.476
7.352.684
- 426 No
Kode
INA-CBG
282
I-4-10-iii
283
I-4-11-i
284
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
10.388.725
10.482.224
10.544.556
10.606.889
4.663.861
4.705.836
4.733.819
4.761.802
I-4-11-ii
5.426.806
5.475.648
5.508.208
5.540.769
285
I-4-11-iii
8.804.979
8.884.224
8.937.054
8.989.883
286
I-4-12-i
4.736.686
4.779.316
4.807.736
4.836.157
287
I-4-12-ii
6.759.238
6.820.071
6.860.626
6.901.182
288
I-4-12-iii
8.199.906
8.273.705
8.322.905
8.372.104
289
I-4-13-i
4.254.846
4.293.140
4.318.669
4.344.198
290
I-4-13-ii
6.181.423
6.237.056
6.274.145
6.311.233
291
I-4-13-iii
10.173.035
10.264.592
10.325.630
10.386.669
292
I-4-14-i
2.646.121
2.669.936
2.685.813
2.701.690
293
I-4-14-ii
3.096.353
3.124.220
3.142.799
3.161.377
294
I-4-14-iii
4.798.317
4.841.502
4.870.292
4.899.082
2.894.297
2.920.345
2.937.711
2.955.077
5.573.202
5.623.360
5.656.800
5.690.239
6.352.109
6.409.278
6.447.390
6.485.503

VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT

295
I-4-15-i
296
I-4-15-ii
297
I-4-15-iii
298
I-4-16-i
2.253.544
2.273.826
2.287.347
2.300.868
299
I-4-16-ii
3.614.379
3.646.908
3.668.595
3.690.281
300
I-4-16-iii
4.537.635
4.578.474
4.605.700
4.632.925
301
I-4-17-i
HIPERTENSI RINGAN
2.613.200
2.636.719
2.652.398
2.668.077
302
I-4-17-ii
HIPERTENSI SEDANG
3.564.880
3.596.964
3.618.353
3.639.743
303
I-4-17-iii
HIPERTENSI BERAT
4.166.629
4.204.129
4.229.129
4.254.128
3.848.493
3.883.129
3.906.220
3.929.311
5.895.633
5.948.694
5.984.068
6.019.441
7.948.258
8.019.793
8.067.482
8.115.172
3.011.950
3.039.057
3.057.129
3.075.201
4.889.464
4.933.469
4.962.806
4.992.143
5.600.726
5.651.132
5.684.737
5.718.341

RINGAN
SEDANG
KONGENITAL BERAT
RINGAN
SEDANG
BERAT
304
I-4-18-i
305
I-4-18-ii
306
I-4-18-iii
307
I-4-19-i
308
I-4-19-ii
309
I-4-19-iii
310
I-4-20-i
3.655.428
3.688.327
3.710.259
3.732.192
311
I-4-20-ii
4.211.326
4.249.228
4.274.496
4.299.764
312
I-4-20-iii
5.589.130
5.639.433
5.672.967
5.706.502
313
I-4-21-i
4.861.127
4.904.878
4.934.044
4.963.211
314
I-4-21-ii
6.063.941
6.118.517
6.154.900
6.191.284
- 427 No
Kode
INA-CBG
315
I-4-21-iii
316
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
8.272.502
8.346.954
8.396.589
8.446.224
I-4-22-i
2.351.616
2.372.781
2.386.890
2.401.000
317
I-4-22-ii
2.709.766
2.734.154
2.750.412
2.766.671
318
I-4-22-iii
3.953.474
3.989.056
4.012.776
4.036.497
1.799.418
1.815.612
1.826.409
1.837.205
2.209.270
2.229.154
2.242.409
2.255.665
4.316.712
4.355.563
4.381.463
4.407.363
2.858.064
2.883.787
2.900.935
2.918.084
7.135.796
7.200.018
7.242.833
7.285.648
9.021.925
9.103.123
9.157.254
9.211.386
23.026.547
23.233.786
23.371.945
23.510.105
24.599.177
24.820.569
24.968.164
25.115.760
42.027.838
42.406.089
42.658.256
42.910.423
11.770.714
11.876.651
11.947.275
12.017.899
12.609.571
12.723.057
12.798.715
12.874.372
18.633.353
18.801.054
18.912.854
19.024.654
4.593.103
4.634.441
4.661.999
4.689.558
11.094.013
11.193.859
11.260.423
11.326.987
16.775.061
16.926.037
17.026.687
17.127.338
3.898.870
3.933.960
3.957.353
3.980.746
5.773.921
5.825.887
5.860.530
5.895.174
7.575.876
7.644.059
7.689.514
7.734.970
2.677.130
2.701.224
2.717.287
2.733.350
11.488.604
11.592.002
11.660.933
11.729.865
31.336.315
31.618.342
31.806.360
31.994.377

RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
319
I-4-23-i
320
I-4-23-ii
321
I-4-23-iii
322
I-4-24-i
323
I-4-24-ii
324
I-4-24-iii
325
J-1-01-i
326
J-1-01-ii
327
J-1-01-iii
328
J-1-02-i
329
J-1-02-ii
330
J-1-02-iii
331
J-1-10-i
332
J-1-10-ii
333
J-1-10-iii
334
J-1-20-i
335
J-1-20-ii
336
J-1-20-iii
337
J-1-30-i
338
J-1-30-ii
339
J-1-30-iii
340
J-4-10-i
2.320.175
2.341.057
2.354.978
2.368.899
341
J-4-10-ii
3.317.572
3.347.430
3.367.335
3.387.241
342
J-4-10-iii
5.018.990
5.064.161
5.094.275
5.124.389
343
J-4-11-i
1.949.249
1.966.792
1.978.488
1.990.183
344
J-4-11-ii
2.713.310
2.737.730
2.754.010
2.770.289
345
J-4-11-iii
3.888.242
3.923.237
3.946.566
3.969.895
- 428 No
Kode
INA-CBG
346
J-4-12-i
347
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
EMBOLI PARU RINGAN
2.238.431
2.258.577
2.272.008
2.285.438
J-4-12-ii
EMBOLI PARU SEDANG
2.898.692
2.924.780
2.942.172
2.959.565
348
J-4-12-iii
EMBOLI PARU BERAT
3.870.910
3.905.748
3.928.974
3.952.199
349
J-4-13-i
4.591.730
4.633.055
4.660.606
4.688.156
350
J-4-13-ii
6.749.843
6.810.591
6.851.091
6.891.590
351
J-4-13-iii
10.974.234
11.073.002
11.138.848
11.204.693
352
J-4-14-i
TUMOR PARU RINGAN
3.129.119
3.157.281
3.176.056
3.194.830
353
J-4-14-ii
TUMOR PARU SEDANG
5.241.702
5.288.878
5.320.328
5.351.778
354
J-4-14-iii
TUMOR PARU BERAT
6.232.118
6.288.207
6.325.599
6.362.992
2.739.424
2.764.079
2.780.516
2.796.952
3.857.272
3.891.988
3.915.131
3.938.275
4.847.157
4.890.781
4.919.864
4.948.947
1.871.207
1.888.048
1.899.275
1.910.502
3.220.436
3.249.419
3.268.742
3.288.065
5.276.804
5.324.295
5.355.956
5.387.617

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
355
J-4-15-i
356
J-4-15-ii
357
J-4-15-iii
358
J-4-16-i
359
J-4-16-ii
360
J-4-16-iii
361
J-4-17-i
2.242.750
2.262.934
2.276.391
2.289.847
362
J-4-17-ii
3.044.062
3.071.459
3.089.723
3.107.987
363
J-4-17-iii
4.882.412
4.926.354
4.955.648
4.984.943
364
J-4-18-i
1.519.994
1.533.674
1.542.794
1.551.914
365
J-4-18-ii
2.325.591
2.346.521
2.360.475
2.374.429
366
J-4-18-iii
2.431.991
2.453.879
2.468.471
2.483.062
367
J-4-19-i
2.842.120
2.867.699
2.884.752
2.901.805
368
J-4-19-ii
3.857.244
3.891.959
3.915.103
3.938.246
369
J-4-19-iii
5.513.713
5.563.337
5.596.419
5.629.501
370
J-4-20-i
3.137.344
3.165.580
3.184.404
3.203.228
371
J-4-20-ii
4.155.282
4.192.679
4.217.611
4.242.542
372
J-4-20-iii
8.282.588
8.357.131
8.406.827
8.456.522
1.746.317
1.762.034
1.772.512
1.782.990
3.890.924
3.925.943
3.949.288
3.972.634
5.428.399
5.477.254
5.509.825
5.542.395
3.898.870
3.933.960
3.957.353
3.980.746
7.318.876
7.384.746
7.428.659
7.472.572
8.571.664
8.648.809
8.700.239
8.751.669
373
J-4-21-i
374
J-4-21-ii
375
J-4-21-iii
376
K-1-10-i
377
K-1-10-ii
378
K-1-10-iii

USUS BESAR (RINGAN)
USUS BESAR (SEDANG)
USUS BESAR (BERAT)
- 429 No
Kode
INA-CBG
Deskripsi (INA-CBG)
379
K-1-11-i
380
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.509.360
4.549.944
4.577.000
4.604.056
K-1-11-ii
5.920.245
5.973.527
6.009.049
6.044.570
381
K-1-11-iii
15.024.417
15.159.636
15.249.783
15.339.929
382
K-1-12-i
2.425.690
2.447.522
2.462.076
2.476.630
383
K-1-12-ii
3.161.425
3.189.878
3.208.846
3.227.815
384
K-1-12-iii
6.288.739
6.345.337
6.383.070
6.420.802
385
K-1-13-i
2.755.252
2.780.049
2.796.581
2.813.112
386
K-1-13-ii
4.812.633
4.855.947
4.884.823
4.913.699
387
K-1-13-iii
5.146.938
5.193.260
5.224.142
5.255.024
388
K-1-14-i
4.452.650
4.492.724
4.519.440
4.546.156
389
K-1-14-ii
5.230.142
5.277.213
5.308.594
5.339.975
390
K-1-14-iii
12.340.792
12.451.859
12.525.904
12.599.948
391
K-1-20-i
8.639.447
8.717.202
8.769.039
8.820.875
392
K-1-20-ii
12.058.390
12.166.915
12.239.265
12.311.616
393
K-1-20-iii
24.707.612
24.929.980
25.078.226
25.226.472
394
K-1-30-i
5.686.914
5.738.096
5.772.218
5.806.339
395
K-1-30-ii
7.797.740
7.867.920
7.914.707
7.961.493
396
K-1-30-iii
16.334.896
16.481.910
16.579.919
16.677.929
397
K-1-40-i
5.713.192
5.764.610
5.798.889
5.833.169
398
K-1-40-ii
6.286.800
6.343.381
6.381.102
6.418.823
399
K-1-40-iii
10.426.052
10.519.887
10.582.443
10.644.999
400
K-1-50-i
4.357.787
4.397.007
4.423.154
4.449.300
401
K-1-50-ii
5.643.539
5.694.331
5.728.192
5.762.054
402
K-1-50-iii
PROSEDUR ANAL BERAT
8.012.325
8.084.436
8.132.510
8.180.584
403
K-4-10-i
3.300.710
3.330.416
3.350.221
3.370.025
404
K-4-10-ii
3.949.493
3.985.039
4.008.736
4.032.433
405
K-4-10-iii
13.307.249
13.427.014
13.506.857
13.586.701
406
K-4-11-i
1.630.609
1.645.285
1.655.068
1.664.852
407
K-4-11-ii
2.646.389
2.670.207
2.686.085
2.701.963
408
K-4-11-iii
4.438.515
4.478.461
4.505.092
4.531.724
409
K-4-12-i
1.664.859
1.679.843
1.689.832
1.699.821
410
K-4-12-ii
2.908.134
2.934.308
2.951.756
2.969.205
411
K-4-12-iii
6.398.019
6.455.601
6.493.989
6.532.377


RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
- 430 No
Kode
INA-CBG
412
K-4-13-i
413
K-4-13-ii
414
K-4-13-iii
415
K-4-14-i
416
K-4-14-ii
417
K-4-14-iii
418
K-4-15-i
419
K-4-15-ii
420
K-4-15-iii
421
K-4-16-i
422
K-4-16-ii
423
K-4-16-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.290.016
2.310.626
2.324.366
2.338.106
2.937.366
2.963.802
2.981.427
2.999.051
4.742.317
4.784.998
4.813.452
4.841.906
1.886.153
1.903.128
1.914.445
1.925.762
2.531.859
2.554.646
2.569.837
2.585.028
4.445.138
4.485.145
4.511.815
4.538.486
1.992.073
2.010.001
2.021.954
2.033.906
3.600.461
3.632.865
3.654.468
3.676.071
5.053.074
5.098.552
5.128.870
5.159.189
2.002.730
2.020.755
2.032.771
2.044.787
2.652.064
2.675.933
2.691.845
2.707.758
3.564.049
3.596.125
3.617.510
3.638.894
1.447.148
1.460.173
1.468.856
1.477.538
2.840.071
2.865.632
2.882.672
2.899.713
3.452.541
3.483.613
3.504.329
3.525.044
1.940.223
1.957.685
1.969.326
1.980.967
3.021.873
3.049.070
3.067.201
3.085.332
3.513.739
3.545.363
3.566.445
3.587.528
19.919.664
20.098.941
20.218.459
20.337.977
20.516.108
20.700.753
20.823.850
20.946.946
28.754.168
29.012.955
29.185.480
29.358.005
6.823.023
6.884.430
6.925.368
6.966.306
13.087.188
13.204.973
13.283.496
13.362.019
13.802.900
13.927.126
14.009.943
14.092.761
3.648.059
3.680.892
3.702.780
3.724.669
7.797.740
7.867.920
7.914.707
7.961.493
11.186.180
11.286.856
11.353.973
11.421.090

(RINGAN)
(SEDANG)
RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
424
K-4-17-i
425
K-4-17-ii
426
K-4-17-iii
427
K-4-18-i
428
K-4-18-ii
429
K-4-18-iii
430
L-1-20-i
431
L-1-20-ii
432
L-1-20-iii
433
L-1-30-i
434
L-1-30-ii
435
L-1-30-iii
436
L-1-40-i
437
L-1-40-ii
438
L-1-40-iii
439
L-1-50-i
4.873.588
4.917.450
4.946.692
4.975.933
440
L-1-50-ii
8.772.458
8.851.410
8.904.045
8.956.680
441
L-1-50-iii
10.607.143
10.702.607
10.766.250
10.829.893
442
L-4-10-i
2.405.313
2.426.961
2.441.393
2.455.825
- 431 No
Kode
INA-CBG
443
L-4-10-ii
444
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.348.231
3.378.365
3.398.455
3.418.544
L-4-10-iii
6.891.027
6.953.046
6.994.393
7.035.739
445
L-4-11-i
2.761.641
2.786.495
2.803.065
2.819.635
446
L-4-11-ii
3.783.399
3.817.450
3.840.150
3.862.851
447
L-4-11-iii
10.260.106
10.352.447
10.414.007
10.475.568
448
L-4-12-i
2.726.226
2.750.762
2.767.119
2.783.476
449
L-4-12-ii
4.284.088
4.322.645
4.348.350
4.374.054
450
L-4-12-iii
6.937.928
7.000.369
7.041.997
7.083.624
451
L-4-13-i
1.832.698
1.849.192
1.860.188
1.871.185
452
L-4-13-ii
2.113.209
2.132.228
2.144.907
2.157.586
453
L-4-13-iii
3.169.978
3.198.508
3.217.528
3.236.547
454
L-4-14-i
1.670.142
1.685.173
1.695.194
1.705.215
455
L-4-14-ii
2.482.262
2.504.602
2.519.496
2.534.389
456
L-4-14-iii
4.565.228
4.606.316
4.633.707
4.661.098
457
M-1-01-i
7.126.445
7.190.583
7.233.342
7.276.101
458
M-1-01-ii
7.954.266
8.025.854
8.073.580
8.121.305
459
M-1-01-iii
11.173.588
11.274.151
11.341.192
11.408.234
460
M-1-02-i
6.721.518
6.782.012
6.822.341
6.862.670
461
M-1-02-ii
11.035.455
11.134.774
11.200.987
11.267.200
462
M-1-02-iii
18.962.073
19.132.732
19.246.504
19.360.277
12.671.328
12.785.370
12.861.398
12.937.426
14.829.160
14.962.622
15.051.597
15.140.572
19.298.536
19.472.223
19.588.015
19.703.806
4.433.984
4.473.890
4.500.494
4.527.098
5.684.322
5.735.480
5.769.586
5.803.692
7.112.857
7.176.873
7.219.550
7.262.227
6.907.296
6.969.461
7.010.905
7.052.349
7.982.983
8.054.830
8.102.728
8.150.626
13.597.194
13.719.569
13.801.152
13.882.735
5.725.551
5.777.081
5.811.435
5.845.788
7.670.449
7.739.484
7.785.506
7.831.529
15.625.433
15.766.062
15.859.814
15.953.567
463
M-1-03-i
464
M-1-03-ii
465
M-1-03-iii
466
M-1-04-i
467
M-1-04-ii
468
M-1-04-iii
469
M-1-05-i
470
M-1-05-ii
471
M-1-05-iii
472
M-1-07-i
473
M-1-07-ii
474
M-1-07-iii


- 432 No
Kode
INA-CBG
475
M-1-10-i
476
M-1-10-ii
477
M-1-10-iii
478
M-1-20-i
479
M-1-20-ii
480
M-1-20-iii
481
M-1-30-i
482
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.765.283
4.808.171
4.836.762
4.865.354
17.700.868
17.860.176
17.966.381
18.072.586
20.637.944
20.823.685
20.947.513
21.071.340
4.714.096
4.756.523
4.784.808
4.813.092
5.340.436
5.388.500
5.420.543
5.452.585
13.079.611
13.197.327
13.275.805
13.354.283
2.819.734
2.845.112
2.862.030
2.878.949
M-1-30-ii
5.826.288
5.878.725
5.913.683
5.948.640
483
M-1-30-iii
PROSEDUR KAKI BERAT
8.691.594
8.769.818
8.821.968
8.874.117
484
M-1-40-i
2.784.489
2.809.549
2.826.256
2.842.963
485
M-1-40-ii
4.583.142
4.624.390
4.651.889
4.679.388
486
M-1-40-iii
6.823.023
6.884.430
6.925.368
6.966.306
487
M-1-50-i
3.773.304
3.807.263
3.829.903
3.852.543
488
M-1-50-ii
6.823.023
6.884.430
6.925.368
6.966.306
489
M-1-50-iii
7.797.740
7.867.920
7.914.707
7.961.493
490
M-1-60-i
2.847.654
2.873.282
2.890.368
2.907.454
491
M-1-60-ii
5.701.021
5.752.330
5.786.536
5.820.742
492
M-1-60-iii
9.921.793
10.011.089
10.070.620
10.130.151
493
M-1-70-i
3.814.711
3.849.043
3.871.931
3.894.820
494
M-1-70-ii
7.783.899
7.853.954
7.900.658
7.947.361
495
M-1-70-iii
12.548.586
12.661.523
12.736.815
12.812.106
496
M-1-80-i
3.073.624
3.101.287
3.119.729
3.138.171
497
M-1-80-ii
4.646.692
4.688.512
4.716.392
4.744.272
498
M-1-80-iii
10.697.888
10.794.169
10.858.356
10.922.544
499
M-4-10-i
1.655.281
1.670.178
1.680.110
1.690.042
500
M-4-10-ii
2.969.966
2.996.695
3.014.515
3.032.335
501
M-4-10-iii
FRAKTUR FEMUR BERAT
6.306.565
6.363.324
6.401.164
6.439.003
502
M-4-11-i
2.576.176
2.599.362
2.614.819
2.630.276
503
M-4-11-ii
5.910.133
5.963.324
5.998.785
6.034.246
504
M-4-11-iii
10.490.347
10.584.760
10.647.703
10.710.645
505
M-4-12-i
1.447.148
1.460.173
1.468.856
1.477.538

TULANG WAJAH RINGAN
TULANG WAJAH SEDANG
TULANG WAJAH BERAT

RINGAN
SEDANG
BERAT

SELAIN KAKI (BERAT)

PANGGUL RINGAN
PANGGUL SEDANG
PANGGUL BERAT
PELVIS RINGAN
- 433 No
Kode
INA-CBG
506
M-4-12-ii
507
M-4-12-iii
508
M-4-13-i
509
M-4-13-ii
510
M-4-13-iii
511
M-4-14-i
512
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.633.085
2.656.783
2.672.581
2.688.380
5.788.593
5.840.691
5.875.422
5.910.154
3.593.526
3.625.868
3.647.429
3.668.991
4.022.975
4.059.182
4.083.320
4.107.458
10.689.841
10.786.049
10.850.188
10.914.328
2.894.297
2.920.345
2.937.711
2.955.077
M-4-14-ii
5.054.320
5.099.809
5.130.135
5.160.461
513
M-4-14-iii
OSTEOMIELITIS BERAT
6.559.873
6.618.912
6.658.271
6.697.631
514
M-4-15-i
2.428.894
2.450.754
2.465.327
2.479.900
515
M-4-15-ii
3.013.568
3.040.690
3.058.771
3.076.853
516
M-4-15-iii
6.775.194
6.836.171
6.876.822
6.917.473
517
M-4-16-i
2.426.547
2.448.386
2.462.945
2.477.505
518
M-4-16-ii
3.545.944
3.577.858
3.599.133
3.620.409
519
M-4-16-iii
7.238.988
7.304.139
7.347.573
7.391.007
520
M-4-17-i
2.078.921
2.097.631
2.110.105
2.122.578
521
M-4-17-ii
2.726.383
2.750.921
2.767.279
2.783.638
522
M-4-17-iii
3.740.769
3.774.436
3.796.880
3.819.325
523
M-4-18-i
2.852.092
2.877.761
2.894.873
2.911.986
524
M-4-18-ii
3.512.276
3.543.886
3.564.960
3.586.033
525
M-4-18-iii
4.836.982
4.880.515
4.909.536
4.938.558
526
M-4-19-i
2.120.569
2.139.654
2.152.378
2.165.101
527
M-4-19-ii
3.394.520
3.425.071
3.445.438
3.465.805
528
M-4-19-iii
5.416.628
5.465.378
5.497.878
5.530.377
529
M-4-20-i
1.580.905
1.595.133
1.604.619
1.614.104
530
M-4-20-ii
2.170.723
2.190.259
2.203.283
2.216.308
531
M-4-20-iii
2.405.672
2.427.323
2.441.757
2.456.191
532
M-4-21-i
1.514.896
1.528.530
1.537.619
1.546.709
533
M-4-21-ii
2.540.754
2.563.621
2.578.865
2.594.110
534
M-4-21-iii
5.245.913
5.293.126
5.324.601
5.356.077
535
N-1-01-i
3.955.014
3.990.609
4.014.339
4.038.069
536
N-1-01-ii
5.349.067
5.397.208
5.429.303
5.461.397

PELVIS SEDANG
PELVIS BERAT

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
RINGAN
SEDANG
BERAT
ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
- 434 No
Kode
INA-CBG
537
N-1-01-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
11.341.613
11.443.687
11.511.737
11.579.787
6.823.023
6.884.430
6.925.368
6.966.306
9.827.177
9.915.622
9.974.585
10.033.548
15.595.481
15.735.840
15.829.413
15.922.986
2.924.153
2.950.470
2.968.015
2.985.560
9.150.508
9.232.863
9.287.766
9.342.669
16.677.371
16.827.467
16.927.531
17.027.596
538
N-1-11-i
539
N-1-11-ii
540
N-1-11-iii
541
N-1-12-i
542
N-1-12-ii
543
N-1-12-iii
544
N-1-20-i
5.325.357
5.373.285
5.405.237
5.437.189
545
N-1-20-ii
10.558.289
10.653.313
10.716.663
10.780.013
546
N-1-20-iii
12.077.725
12.186.425
12.258.891
12.331.358
6.335.452
6.392.471
6.430.483
6.468.496
9.627.509
9.714.156
9.771.921
9.829.686
10.611.677
10.707.182
10.770.852
10.834.522
5.708.862
5.760.242
5.794.495
5.828.748
7.738.566
7.808.213
7.854.645
7.901.076
9.000.176
9.081.177
9.135.178
9.189.180
2.221.835
2.241.832
2.255.163
2.268.494
3.258.127
3.287.450
3.306.999
3.326.548
6.420.721
6.478.507
6.517.032
6.555.556


URIN BAWAH RINGAN
URIN BAWAH SEDANG
URIN BAWAH BERAT
RINGAN
SEDANG
BERAT
GINJAL RINGAN
GINJAL SEDANG
GINJAL BERAT
547
N-1-30-i
548
N-1-30-ii
549
N-1-30-iii
550
N-1-40-i
551
N-1-40-ii
552
N-1-40-iii
553
N-4-10-i
554
N-4-10-ii
555
N-4-10-iii
556
N-4-11-i
1.863.355
1.880.125
1.891.305
1.902.485
557
N-4-11-ii
3.149.025
3.177.366
3.196.260
3.215.154
558
N-4-11-iii
3.603.512
3.635.944
3.657.565
3.679.186
559
N-4-12-i
1.801.777
1.817.993
1.828.804
1.839.615
560
N-4-12-ii
2.532.349
2.555.140
2.570.335
2.585.529
561
N-4-12-iii
3.980.171
4.015.992
4.039.873
4.063.755
562
N-4-13-i
BATU URIN RINGAN
2.568.114
2.591.227
2.606.636
2.622.045
563
N-4-13-ii
BATU URIN SEDANG
3.096.180
3.124.046
3.142.623
3.161.200
564
N-4-13-iii
BATU URIN BERAT
7.625.043
7.693.668
7.739.418
7.785.169
565
N-4-14-i
1.266.119
1.277.514
1.285.111
1.292.707
566
N-4-14-ii
1.949.664
1.967.211
1.978.909
1.990.607

(RINGAN)
(SEDANG)
- 435 No
Kode
INA-CBG
567
N-4-14-iii
568
N-4-15-i
569
N-4-15-ii
570
N-4-15-iii
571
N-4-16-i
572
N-4-16-ii
573
N-4-16-iii
574
O-6-10-i
575
O-6-10-ii
576
O-6-10-iii
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
584
O-6-13-ii
585
O-6-13-iii
586
P-8-01-i
587
P-8-01-ii
588
P-8-01-iii
589
P-8-02-i
590
P-8-02-ii
591
P-8-02-iii
592
P-8-03-i
593
P-8-03-ii
594
P-8-03-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.161.733
3.190.189
3.209.159
3.228.129
2.501.437
2.523.950
2.538.959
2.553.967
3.432.750
3.463.645
3.484.241
3.504.838
3.917.387
3.952.644
3.976.148
3.999.652
2.512.239
2.534.849
2.549.922
2.564.996
3.241.983
3.271.161
3.290.613
3.310.065
6.466.098
6.524.293
6.563.090
6.601.886
3.124.760
3.152.883
3.171.631
3.190.380
3.468.960
3.500.181
3.520.994
3.541.808
4.274.934
4.313.408
4.339.058
4.364.707
1.972.703
1.990.457
2.002.293
2.014.129
3.214.111
3.243.038
3.262.323
3.281.607
5.446.921
5.495.943
5.528.625
5.561.306
2.181.654
2.201.289
2.214.379
2.227.469
2.620.161
2.643.743
2.659.463
2.675.184
3.291.857
3.321.484
3.341.235
3.360.986
1.545.967
1.559.881
1.569.157
1.578.432
1.806.069
1.822.324
1.833.160
1.843.997
2.246.087
2.266.301
2.279.778
2.293.254
36.726.893
37.057.435
37.277.796
37.498.158
45.443.785
45.852.779
46.125.442
46.398.104
53.338.264
53.818.309
54.138.338
54.458.368
59.257.092
59.790.406
60.145.948
60.501.491
67.973.984
68.585.750
68.993.594
69.401.438
77.665.137
78.364.123
78.830.114
79.296.105
2.436.794
2.458.725
2.473.346
2.487.967
3.629.514
3.662.180
3.683.957
3.705.734
6.596.195
6.655.561
6.695.138
6.734.715

(BERAT)
SALURAN URIN RINGAN
SALURAN URIN SEDANG
SALURAN URIN BERAT
RINGAN
SEDANG
BERAT
&KURET RINGAN
KURET SEDANG
KURET BERAT

- 436 No
Kode
INA-CBG
595
P-8-04-i
596
P-8-04-ii
597
P-8-04-iii
598
P-8-05-i
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii
603
P-8-06-iii
604
P-8-07-i
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
614
P-8-11-ii
615
P-8-11-iii
616
P-8-12-i
617
P-8-12-ii
618
P-8-12-iii
619
P-8-13-i
620
P-8-13-ii
621
P-8-13-iii
622
P-8-14-i
Deskripsi (INA-CBG)
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
RINGAN
SEDANG
BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
29.272.494
29.535.947
29.711.582
29.887.217
37.989.386
38.331.291
38.559.227
38.787.164
54.467.218
54.957.423
55.284.226
55.611.030
15.917.433
16.060.690
16.156.195
16.251.699
22.560.816
22.763.863
22.899.228
23.034.593
33.240.334
33.539.497
33.738.939
33.938.381
2.229.026
2.249.087
2.262.461
2.275.835
5.848.305
5.900.940
5.936.030
5.971.120
10.721.893
10.818.390
10.882.721
10.947.053
4.230.049
4.268.119
4.293.500
4.318.880
10.445.548
10.539.558
10.602.231
10.664.904
14.045.663
14.172.074
14.256.348
14.340.622
3.325.443
3.355.372
3.375.325
3.395.277
4.720.934
4.763.422
4.791.748
4.820.074
6.028.109
6.082.362
6.118.531
6.154.699
2.063.101
2.081.669
2.094.047
2.106.426
2.988.702
3.015.600
3.033.533
3.051.465
5.867.703
5.920.512
5.955.718
5.990.925
2.034.650
2.052.962
2.065.170
2.077.377
12.370.542
12.481.877
12.556.101
12.630.324
12.629.707
12.743.375
12.819.153
12.894.931
2.741.274
2.765.946
2.782.393
2.798.841
4.262.205
4.300.565
4.326.138
4.351.711
5.028.501
5.073.757
5.103.928
5.134.099
1.416.838
1.429.590
1.438.091
1.446.592
2.621.848
2.645.445
2.661.176
2.676.907
3.921.254
3.956.545
3.980.073
4.003.600
2.588.711
2.612.009
2.627.541
2.643.074
- 437 No
Kode
INA-CBG
623
P-8-14-ii
624
P-8-14-iii
625
P-8-15-i
626
P-8-15-ii
627
P-8-15-iii
628
P-8-16-i
629
P-8-16-ii
630
P-8-16-iii
631
P-8-17-i
632
P-8-17-ii
633
P-8-17-iii
634
S-4-10-i
635
S-4-10-ii
636
S-4-10-iii
637
S-4-11-i
638
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.285.415
5.332.983
5.364.696
5.396.408
5.798.080
5.850.263
5.885.051
5.919.840
1.946.791
1.964.312
1.975.993
1.987.674
3.891.124
3.926.144
3.949.491
3.972.837
4.570.727
4.611.864
4.639.288
4.666.712
1.762.306
1.778.167
1.788.741
1.799.315
2.499.906
2.522.406
2.537.405
2.552.405
3.245.002
3.274.207
3.293.677
3.313.147
1.161.007
1.171.456
1.178.422
1.185.388
3.863.485
3.898.257
3.921.438
3.944.618
7.798.199
7.868.383
7.915.172
7.961.961
1.447.148
1.460.173
1.468.856
1.477.538
1.808.935
1.825.216
1.836.069
1.846.923
2.351.306
2.372.467
2.386.575
2.400.683
904.468
912.608
918.035
923.462
S-4-11-ii
1.447.148
1.460.173
1.468.856
1.477.538
639
S-4-11-iii
2.227.125
2.247.170
2.260.532
2.273.895
640
S-4-12-i
1.115.504
1.125.543
1.132.237
1.138.930
641
S-4-12-ii
1.525.722
1.539.454
1.548.608
1.557.762
642
S-4-12-iii
2.918.855
2.945.125
2.962.638
2.980.151
643
S-4-13-i
1.733.673
1.749.276
1.759.678
1.770.080
644
S-4-13-ii
2.855.944
2.881.648
2.898.784
2.915.919
645
S-4-13-iii
5.533.286
5.583.086
5.616.286
5.649.485
646
S-4-14-i
890.598
898.613
903.957
909.301
647
S-4-14-ii
1.891.929
1.908.956
1.920.308
1.931.659
648
S-4-14-iii
3.587.771
3.620.061
3.641.588
3.663.114
649
S-4-15-i
673.567
679.630
683.671
687.712
650
S-4-15-ii
1.271.251
1.282.692
1.290.320
1.297.947
651
S-4-15-iii
1.646.566
1.661.385
1.671.264
1.681.144
652
S-4-16-i
LUKA BAKAR RINGAN
2.765.156
2.790.042
2.806.633
2.823.224
653
S-4-16-ii
LUKA BAKAR SEDANG
4.811.066
4.854.365
4.883.232
4.912.098
654
S-4-16-iii
LUKA BAKAR BERAT
8.590.905
8.668.223
8.719.769
8.771.314

ASPIRASI RINGAN
ASPIRASI SEDANG
ASPIRASI BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT

PASIEN RINGAN
PASIEN SEDANG
PASIEN BERAT
- 438 No
Kode
INA-CBG
655
S-4-17-i
656
S-4-17-ii
657
S-4-17-iii
658
T-1-10-i
659
T-1-10-ii
660
T-1-10-iii
661
T-4-10-i
662
T-4-10-ii
663
T-4-10-iii
664
T-4-11-i
665
T-4-11-ii
666
T-4-11-iii
667
T-4-12-i
668
T-4-12-ii
669
T-4-12-iii
670
U-1-10-i
671
U-1-10-ii
672
U-1-10-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.816.404
1.832.752
1.843.650
1.854.549
2.115.390
2.134.428
2.147.121
2.159.813
3.267.767
3.297.177
3.316.784
3.336.390
1.875.031
1.891.906
1.903.156
1.914.406
2.518.039
2.540.701
2.555.809
2.570.918
4.581.134
4.622.364
4.649.851
4.677.337
615.901
621.444
625.139
628.835
1.173.770
1.184.334
1.191.377
1.198.419
1.706.343
1.721.700
1.731.938
1.742.176
811.123
818.423
823.290
828.156
1.276.476
1.287.965
1.295.624
1.303.282
2.056.027
2.074.532
2.086.868
2.099.204
1.334.908
1.346.923
1.354.932
1.362.942
1.989.048
2.006.950
2.018.884
2.030.818
3.063.181
3.090.750
3.109.129
3.127.508
1.361.382
1.373.634
1.381.803
1.389.971
2.777.983
2.802.985
2.819.653
2.836.321
11.995.893
12.103.856
12.175.832
12.247.807
5.848.305
5.900.940
5.936.030
5.971.120
7.797.740
7.867.920
7.914.707
7.961.493
17.622.048
17.780.647
17.886.379
17.992.111

DOKTER RINGAN
DOKTER SEDANG
DOKTER BERAT

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
673
U-1-11-i
674
U-1-11-ii
675
U-1-11-iii
676
U-1-12-i
4.807.345
4.850.611
4.879.455
4.908.300
677
U-1-12-ii
8.772.458
8.851.410
8.904.045
8.956.680
678
U-1-12-iii
11.391.203
11.493.724
11.562.071
11.630.418
679
U-1-13-i
3.898.870
3.933.960
3.957.353
3.980.746
680
U-1-13-ii
4.873.588
4.917.450
4.946.692
4.975.933
681
U-1-13-iii
8.482.481
8.558.823
8.609.718
8.660.613
2.893.684
2.919.727
2.937.089
2.954.451
3.551.132
3.583.092
3.604.399
3.625.705
4.208.191
4.246.065
4.271.314
4.296.563
1.699.571
1.714.867
1.725.064
1.735.262
682
U-1-14-i
683
U-1-14-ii
684
U-1-14-iii
685
U-1-15-i

- 439 No
Kode
INA-CBG
686
U-1-15-ii
687
U-1-15-iii
688
U-1-20-i
689
U-1-20-ii
690
U-1-20-iii
691
U-1-30-i
692
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.414.971
2.436.706
2.451.196
2.465.686
4.758.798
4.801.627
4.830.180
4.858.733
4.396.049
4.435.614
4.461.990
4.488.366
6.910.432
6.972.626
7.014.089
7.055.551
14.351.682
14.480.847
14.566.957
14.653.067
3.771.044
3.804.983
3.827.609
3.850.235
U-1-30-ii
5.090.909
5.136.727
5.167.272
5.197.818
693
U-1-30-iii
7.797.740
7.867.920
7.914.707
7.961.493
694
U-4-10-i
3.510.212
3.541.804
3.562.865
3.583.926
695
U-4-10-ii
8.799.364
8.878.558
8.931.354
8.984.150
696
U-4-10-iii
12.836.355
12.951.882
13.028.901
13.105.919
697
U-4-11-i
1.629.013
1.643.674
1.653.449
1.663.223
698
U-4-11-ii
2.170.723
2.190.259
2.203.283
2.216.308
699
U-4-11-iii
4.038.132
4.074.476
4.098.704
4.122.933
700
U-4-12-i
1.447.148
1.460.173
1.468.856
1.477.538
701
U-4-12-ii
2.269.244
2.289.667
2.303.282
2.316.898
702
U-4-12-iii
3.607.994
3.640.466
3.662.114
3.683.762
703
U-4-13-i
1.447.148
1.460.173
1.468.856
1.477.538
704
U-4-13-ii
1.652.829
1.667.704
1.677.621
1.687.538
705
U-4-13-iii
2.524.308
2.547.026
2.562.172
2.577.318
706
U-4-14-i
1.808.935
1.825.216
1.836.069
1.846.923
707
U-4-14-ii
2.170.723
2.190.259
2.203.283
2.216.308
708
U-4-14-iii
3.659.387
3.692.322
3.714.278
3.736.234
1.558.781
1.572.810
1.582.163
1.591.516
2.052.852
2.071.327
2.083.644
2.095.962
2.784.207
2.809.264
2.825.970
2.842.675
4.808.483
4.851.760
4.880.611
4.909.462
5.458.051
5.507.174
5.539.922
5.572.670
9.259.817
9.343.155
9.398.714
9.454.273


DAN TELINGA RINGAN
DAN TELINGA SEDANG
DAN TELINGA BERAT


KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT
709
U-4-15-i
710
U-4-15-ii
711
U-4-15-iii
712
V-1-10-i
713
V-1-10-ii
714
V-1-10-iii
715
V-1-11-i
4.873.588
4.917.450
4.946.692
4.975.933
716
V-1-11-ii
5.439.006
5.487.957
5.520.591
5.553.225
717
V-1-11-iii
8.054.335
8.126.824
8.175.150
8.223.476
718
V-1-12-i

3.540.483
3.572.348
3.593.591
3.614.833
- 440 No
Kode
INA-CBG
719
V-1-12-ii
720
V-1-12-iii
721
V-1-13-i
722
V-1-13-ii
723
V-1-13-iii
724
V-1-14-i
725
V-1-14-ii
726
V-1-14-iii
727
V-1-15-i
728
V-1-15-ii
729
V-1-15-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
10.807.882
10.905.153
10.970.000
11.034.848
12.154.881
12.264.275
12.337.204
12.410.133
5.366.225
5.414.521
5.446.718
5.478.916
10.197.367
10.289.144
10.350.328
10.411.512
11.696.611
11.801.880
11.872.060
11.942.239
6.469.047
6.527.268
6.566.082
6.604.896
9.408.674
9.493.352
9.549.804
9.606.256
12.730.302
12.844.875
12.921.257
12.997.639
2.924.153
2.950.470
2.968.015
2.985.560
4.563.332
4.604.402
4.631.782
4.659.162
7.592.418
7.660.750
7.706.304
7.751.859
4.910.940
4.955.139
4.984.604
5.014.070
6.343.066
6.400.154
6.438.212
6.476.270
12.122.712
12.231.817
12.304.553
12.377.289
2.497.397
2.519.874
2.534.858
2.549.842
3.649.096
3.681.938
3.703.833
3.725.727
6.020.767
6.074.954
6.111.078
6.147.203
7.343.570
7.409.662
7.453.724
7.497.785
8.844.982
8.924.587
8.977.657
9.030.727
16.015.479
16.159.618
16.255.711
16.351.804

NON KOMPLEK (BERAT)

RINGAN
SEDANG
BERAT
730
V-4-10-i
731
V-4-10-ii
732
V-4-10-iii
733
V-4-11-i
734
V-4-11-ii
735
V-4-11-iii
736
W-1-01-i
737
W-1-01-ii
738
W-1-01-iii
739
W-1-10-i
1.949.435
1.966.980
1.978.677
1.990.373
740
W-1-10-ii
3.816.633
3.850.983
3.873.883
3.896.782
741
W-1-10-iii
6.242.801
6.298.986
6.336.443
6.373.900
742
W-1-11-i
2.124.257
2.143.375
2.156.121
2.168.867
743
W-1-11-ii
3.898.870
3.933.960
3.957.353
3.980.746
744
W-1-11-iii
5.848.305
5.900.940
5.936.030
5.971.120
745
W-1-12-i
1.930.207
1.947.579
1.959.160
1.970.741
746
W-1-12-ii
2.194.608
2.214.360
2.227.527
2.240.695
747
W-1-12-iii
3.371.195
3.401.536
3.421.763
3.441.990
748
W-1-13-i
1.725.172
1.740.698
1.751.049
1.761.400
749
W-1-13-ii
1.873.039
1.889.897
1.901.135
1.912.373
750
W-1-13-iii
2.515.837
2.538.480
2.553.575
2.568.670

SERVIK RINGAN
SERVIK SEDANG
SERVIK BERAT
ENDOSKOP RINGAN
ENDOSKOP SEDANG
ENDOSKOP BERAT
- 441 No
Kode
INA-CBG
751
W-1-20-i
752
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
6.259.767
6.316.105
6.353.664
6.391.222
W-1-20-ii
7.797.740
7.867.920
7.914.707
7.961.493
753
W-1-20-iii
8.772.458
8.851.410
8.904.045
8.956.680
754
W-1-30-i
3.417.205
3.447.960
3.468.463
3.488.966
755
W-1-30-ii
4.873.588
4.917.450
4.946.692
4.975.933
756
W-1-30-iii
14.494.537
14.624.988
14.711.955
14.798.922
757
W-4-10-i
2.548.379
2.571.314
2.586.605
2.601.895
758
W-4-10-ii
3.444.420
3.475.419
3.496.086
3.516.752
759
W-4-10-iii
6.191.733
6.247.458
6.284.609
6.321.759
760
W-4-11-i
1.808.935
1.825.216
1.836.069
1.846.923
761
W-4-11-ii
3.035.737
3.063.059
3.081.273
3.099.487
762
W-4-11-iii
3.665.142
3.698.128
3.720.119
3.742.110
763
W-4-12-i
1.447.148
1.460.173
1.468.856
1.477.538
764
W-4-12-ii
2.473.383
2.495.643
2.510.483
2.525.324
765
W-4-12-iii
2.984.027
3.010.883
3.028.787
3.046.691
766
W-4-13-i
ABORTUS RINGAN
793.633
800.776
805.538
810.300
767
W-4-13-ii
ABORTUS SEDANG
1.085.361
1.095.130
1.101.642
1.108.154
768
W-4-13-iii
ABORTUS BERAT
1.447.148
1.460.173
1.468.856
1.477.538
769
W-4-14-i
1.085.361
1.095.130
1.101.642
1.108.154
770
W-4-14-ii
1.447.148
1.460.173
1.468.856
1.477.538
771
W-4-14-iii
1.756.532
1.772.341
1.782.880
1.793.419
772
W-4-15-i
1.085.361
1.095.130
1.101.642
1.108.154
773
W-4-15-ii
1.166.493
1.176.992
1.183.991
1.190.990
774
W-4-15-iii
1.475.821
1.489.103
1.497.958
1.506.813
775
W-4-16-i
1.221.399
1.232.392
1.239.720
1.247.049
776
W-4-16-ii
1.935.073
1.952.489
1.964.099
1.975.709
777
W-4-16-iii
2.466.209
2.488.404
2.503.202
2.517.999
778
W-4-17-i
1.085.361
1.095.130
1.101.642
1.108.154
779
W-4-17-ii
1.447.148
1.460.173
1.468.856
1.477.538
780
W-4-17-iii
2.737.717
2.762.356
2.778.783
2.795.209
781
Z-4-10-i
REHABILITASI RINGAN
2.508.135
2.530.708
2.545.757
2.560.806
782
Z-4-10-ii
REHABILITASI SEDANG
3.329.187
3.359.150
3.379.125
3.399.100
783
Z-4-10-iii
REHABILITASI BERAT
4.729.428
4.771.993
4.800.370
4.828.746
784
Z-4-11-i
2.915.514
2.941.754
2.959.247
2.976.740

RINGAN
SEDANG
BERAT

- 442 No
Kode
INA-CBG
Deskripsi (INA-CBG)
785
Z-4-11-ii
786
Z-4-11-iii
787
Z-4-12-i
788
Z-4-12-ii
789
Z-4-12-iii
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.509.635
3.541.222
3.562.279
3.583.337
5.486.831
5.536.213
5.569.134
5.602.055
1.127.650
1.137.799
1.144.565
1.151.331
2.974.543
3.001.314
3.019.161
3.037.008
3.780.173
3.814.195
3.836.876
3.859.557

- 443 2. RawatJalan
No
Kode
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
600.126
605.527
609.128
612.729
778.457
785.464
790.134
794.805
1.447.644
1.460.673
1.469.359
1.478.045
1.196.337
1.207.104
1.214.282
1.221.461
999.437
1.008.432
1.014.428
1.020.425
350.407
353.561
355.663
357.766
781.362
788.394
793.082
797.770
B-3-12-0

160.544
161.989
162.952
163.916
C-3-10-0
437.942
441.883
444.511
447.138
10
C-3-11-0

KANDUNG KEMIH
692.621
698.855
703.011
707.166
11
C-3-12-0
157.016
158.429
159.371
160.313
152.473
153.845
154.760
155.675
1.298.006
1.309.688
1.317.476
1.325.264
1.189.674
1.200.381
1.207.519
1.214.657

LAPAROSKOPI
PANKREAS
LAPAROSKOPI
EMPEDU

OVARIUM
GASTROINTESTINAL
GINJAL ATAU PROSTAT
12
C-3-13-0
13
C-3-14-0
14
C-3-15-0
15
C-3-16-0
269.789
272.218
273.836
275.455
16
C-3-17-0

LEHER
178.970
180.581
181.655
182.729
17
C-3-18-0
79.348
80.062
80.538
81.014
18
C-3-19-0

MYELOMA ATAU TESTIS
112.214
113.224
113.897
114.570
19
C-3-20-0
2.234.742
2.254.855
2.268.263
2.281.672
20
C-3-21-0
128.056
129.209
129.977
130.745
21
C-3-22-0
562.234
567.294
570.668
574.041
22
C-3-23-0
91.070
91.889
92.436
92.982
23
D-2-10-0

TULANG
771.555
778.499
783.128
787.758
24
D-2-11-0
PROSEDUR LIMPA
966.119
974.814
980.611
986.407
25
D-2-21-0
810.300
817.593
822.455
827.316
26
D-2-22-0
177.836
179.437
180.504
181.571
27
D-3-10-0
128.811
129.971
130.744
131.516
28
D-3-11-0
334.431
337.441
339.448
341.454
29
E-2-10-0
198.382
200.168
201.358
202.548
30
E-2-21-0
143.820
145.115
145.978
146.840
31
E-2-22-0
143.820
145.115
145.978
146.840

TYMUS
TYMUS
TULANG
PEMBENTUK DARAH
DAN PARATIROID
THYROGLOSSAL
- 444 No
Kode
INA-CBG
32
E-3-10-0
33
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

ENDOKRIN
167.254
168.759
169.762
170.766
F-3-10-0
TERAPI SHOCK
233.313
235.413
236.813
238.213
34
F-5-10-0
285.884
288.457
290.173
291.888
35
F-5-11-0
TERAPI KELOMPOK
188.515
190.211
191.342
192.473
36
F-5-12-0
241.236
243.407
244.855
246.302
37
F-5-13-0
204.311
206.150
207.376
208.602
38
F-5-14-0
137.065
138.299
139.121
139.944
39
F-5-15-0
128.585
129.742
130.514
131.285
40
F-5-16-0
133.934
135.139
135.943
136.746
41
G-2-10-0
PROSEDUR KRANIOTOMI
112.782
113.797
114.474
115.151
42
G-2-11-0
977.646
986.445
992.310
998.176
43
G-2-12-0

EKSTRAKRANIAL
1.416.849
1.429.601
1.438.102
1.446.603
44
G-2-13-0
347.585
350.713
352.799
354.884
45
G-2-21-0
633.936
639.641
643.445
647.249
46
G-2-22-0
575.351
580.529
583.981
587.433
47
G-2-31-0
949.379
957.923
963.620
969.316
48
G-2-32-0
486.651
491.031
493.951
496.871
49
G-3-10-0
193.155
194.893
196.052
197.211
50
G-3-11-0
257.245
259.560
261.104
262.647
51
G-3-12-0
421.501
425.294
427.823
430.352
52
G-3-13-0
421.549
425.343
427.872
430.401
53
H-2-21-0
553.220
558.199
561.518
564.838
54
H-2-22-0
143.820
145.115
145.978
146.840
55
H-2-23-0
143.820
145.115
145.978
146.840
56
H-2-31-0
916.363
924.610
930.109
935.607
57
H-2-32-0
95.372
96.230
96.803
97.375
58
H-2-33-0
143.820
145.115
145.978
146.840
59
H-2-34-0
411.103
414.803
417.269
419.736
60
H-2-35-0
135.468
136.687
137.500
138.313
61
H-2-36-0
731.223
737.804
742.191
746.579
62
H-2-37-0

778.419
785.425
790.095
794.766
63
H-3-10-0
270.833
273.270
274.895
276.520
64
H-3-11-0
142.428
143.710
144.565
145.419

AKUT
MENTAL

MATA
MATA
MATA
MATA
MATA
- 445 No
Kode
INA-CBG
65
H-3-12-0
66
H-3-13-0
67
I-2-11-0
68
I-2-12-0
69
I-2-13-0
70
I-2-14-0
71
I-2-15-0
Deskripsi (INA-CBG)
MATA
TORASIK
ABDOMEN
PENGGANTIAN ALAT
DARAH VENA
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
148.702
150.041
150.933
151.825
144.381
145.680
146.547
147.413
1.665.019
1.680.005
1.689.995
1.699.985
1.170.690
1.181.227
1.188.251
1.195.275
1.487.877
1.501.268
1.510.195
1.519.122
2.633.225
2.656.924
2.672.724
2.688.523
158.357
159.782
160.732
161.683
1.663.215
1.678.184
1.688.163
1.698.142
548.314
553.249
556.539
559.829
72
I-2-16-0
73
I-2-17-0
74
I-2-21-0
1.283.765
1.295.319
1.303.022
1.310.725
75
I-2-22-0
1.208.890
1.219.770
1.227.023
1.234.277
76
I-2-23-0
247.396
249.622
251.107
252.591
77
I-2-31-0
1.924.080
1.941.397
1.952.941
1.964.486
78
I-2-32-0
2.516.017
2.538.661
2.553.758
2.568.854
79
I-2-41-0
1.687.020
1.702.204
1.712.326
1.722.448
80
I-2-42-0

LAIN
1.961.440
1.979.093
1.990.862
2.002.631
81
I-3-10-0
PROSEDUR RESUSITASI
248.987
251.228
252.722
254.216
82
I-3-11-0
131.415
132.598
133.386
134.175
83
I-3-12-0
763.734
770.608
775.190
779.773
84
I-3-13-0
250.840
253.098
254.603
256.108
85
I-3-14-0
160.780
162.227
163.192
164.156
142.428
143.710
144.565
145.419
881.823
889.760
895.051
900.342
142.150
143.429
144.282
145.135

PACU JANTUNG

KARDIOVASKULAR
PERNAFASAN
PENDEK
86
I-3-15-0
87
J-2-10-0
88
J-2-21-0
89
J-2-22-0
716.346
722.793
727.091
731.389
90
J-2-31-0
PROSEDUR
929.165
937.527
943.102
948.677
91
J-2-32-0
691.453
697.676
701.825
705.973
92
J-3-10-0
143.820
145.115
145.978
146.840
93
J-3-11-0

PADA DADA
406.410
410.068
412.507
414.945
94
J-3-12-0
157.016
158.429
159.371
160.313
95
J-3-13-0
231.088
233.168
234.554
235.941
96
J-3-14-0
245.325
247.533
249.005
250.477
- 446 No
Kode
INA-CBG
97
J-3-15-0
98
J-3-16-0
99
J-3-17-0
100
K-2-10-0
101
K-2-11-0
102
K-2-12-0
103
K-2-13-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
215.131
217.067
218.357
219.648
245.325
247.533
249.005
250.477
143.820
145.115
145.978
146.840
413.964
417.690
420.173
422.657
883.982
891.938
897.242
902.545

678.570
684.677
688.749
692.820
1.104.410
1.114.349
1.120.976
1.127.602
143.820
145.115
145.978
146.840
143.820
145.115
145.978
146.840
1.848.433
1.865.069
1.876.159
1.887.250
621.534
627.128
630.857
634.586
143.820
145.115
145.978
146.840

PERNAFASAN
KECIL

FEMORALIS
USUS BESAR
ATAS
ATAS
104
K-2-14-0
105
K-2-21-0
106
K-2-22-0
107
K-2-31-0
108
K-2-32-0
109
K-2-41-0
684.633
690.794
694.902
699.010
110
K-2-42-0

195.608
197.368
198.542
199.716
111
K-2-51-0
453.679
457.762
460.484
463.206
112
K-2-52-0
247.396
249.622
251.107
252.591
113
K-2-53-0
143.820
145.115
145.978
146.840
114
K-3-10-0

GASTROINTESTINAL
273.680
276.143
277.785
279.428
115
K-3-11-0
164.535
166.016
167.003
167.991
116
K-3-12-0
166.860
168.361
169.362
170.364
117
K-3-13-0
143.820
145.115
145.978
146.840
385.442
388.910
391.223
393.536
186.135
187.810
188.927
190.044
246.641
248.861
250.340
251.820
847.960
855.592
860.679
865.767
543.536
548.428
551.689
554.951
245.325
247.533
249.005
250.477
247.396
249.622
251.107
252.591

GASTROINTESTINAL
LUKA BAKAR
LUKA BAKAR
TANPA LUKA BAKAR
LUKA BAKAR
118
K-3-14-0
119
K-3-15-0
120
K-3-16-0
121
L-2-21-0
122
L-2-22-0
123
L-2-31-0
124
L-2-32-0
125
L-2-41-0
740.797
747.464
751.909
756.354
126
L-2-42-0

166.149
167.644
168.641
169.638
127
L-2-51-0
1.109.089
1.119.071
1.125.726
1.132.380
L-2-52-0

848.490
856.126
861.217
866.308
128
- 447 No
Kode
INA-CBG
129
L-2-53-0
130
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

143.820
145.115
145.978
146.840
L-3-10-0
195.608
197.368
198.542
199.716
131
L-3-11-0
189.949
191.658
192.798
193.938
132
L-3-12-0
144.664
145.966
146.834
147.702
133
M-2-10-0
1.134.679
1.144.891
1.151.699
1.158.508
134
M-2-21-0
1.016.184
1.025.329
1.031.427
1.037.524
135
M-2-22-0
247.396
249.622
251.107
252.591
136
M-2-31-0
PROSEDUR BUNION
617.230
622.785
626.488
630.191
137
M-2-32-0
195.608
197.368
198.542
199.716
138
M-2-41-0

TULANG
195.608
197.368
198.542
199.716
139
M-2-42-0
67.412
68.019
68.423
68.828
140
M-2-51-0
143.820
145.115
145.978
146.840
141
M-2-52-0
143.820
145.115
145.978
146.840
142
M-2-61-0
PROSEDUR ARTROSKOPI
704.938
711.283
715.512
719.742
143
M-2-62-0
143.820
145.115
145.978
146.840
708.752
715.131
719.383
723.636
966.591
975.290
981.090
986.890
143.820
145.115
145.978
146.840
713.598
720.021
724.302
728.584
688.653
694.851
698.983
703.115
1.026.928
1.036.170
1.042.332
1.048.493
745.997
752.711
757.187
761.663
143.820
145.115
145.978
146.840
143.820
145.115
145.978
146.840
410.491
414.185
416.648
419.111
227.592
229.640
231.006
232.372
514.682
519.314
522.402
525.491
144
M-2-63-0
145
M-2-64-0
146
M-2-65-0
147
M-2-71-0
148
M-2-72-0
149
M-2-81-0
150
M-2-82-0
151
M-2-83-0
152
M-2-84-0
153
M-3-10-0

DAN WAJAH
PAHA
PAHA

TULANG
WAJAH
WAJAH
BAWAH
BAWAH
BAHU
PERGELANGAN TANGAN
PERGELANGAN TANGAN
MUSKULOSKELETAL
SKELETAL
154
M-3-11-0
155
M-3-12-0
156
M-3-13-0
167.800
169.310
170.317
171.324
157
M-3-14-0

TERTUTUP
286.799
289.380
291.101
292.822
158
M-3-15-0
126.353
127.490
128.248
129.006
159
M-3-16-0

143.820
145.115
145.978
146.840
160
M-3-17-0
157.016
158.429
159.371
160.313
161
N-2-11-0
1.900.007
1.917.107
1.928.507
1.939.907
- 448 No
Kode
INA-CBG
162
N-2-12-0
163
N-2-21-0
164
N-2-22-0
165
N-2-23-0
166
N-2-24-0
167
N-2-31-0
168
N-2-32-0
169
N-2-41-0
170
N-2-42-0
171
N-3-10-0
172
N-3-11-0
173
N-3-12-0
174
N-3-13-0
175
N-3-14-0
176
N-3-15-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.099.135
1.109.027
1.115.622
1.122.217
1.093.342
1.103.182
1.109.742
1.116.302
247.396
249.622
251.107
252.591

URETER
247.396
249.622
251.107
252.591
799.500
806.695
811.492
816.289
673.049
679.107
683.145
687.183
247.396
249.622
251.107
252.591
247.396
249.622
251.107
252.591
418.394
422.159
424.669
427.180
247.396
249.622
251.107
252.591
286.643
289.223
290.943
292.663
221.502
223.495
224.824
226.153
247.396
249.622
251.107
252.591
212.871
214.786
216.064
217.341
545.854
550.766
554.042
557.317
91.134
91.954
92.501
93.048
501.899
506.416
509.428
512.439
182.758
184.403
185.500
186.596
101.569
102.483
103.093
103.702
135.468
136.687
137.500
138.313


DAN URETHRA
DAN URETHRA
TRANSURETHRA
TRANSURETHRA
SALURAN KEMIH
KEMIH
KEMIH
PROSEDUR DIALISIS
CAESAR
VAGINAL/JALAN LAHIR
177
O-7-10-0
178
O-7-11-0
179
O-7-12-0
180
O-7-13-0
181
P-9-10-0
182
P-9-11-0
135.468
136.687
137.500
138.313
183
P-9-12-0
135.468
136.687
137.500
138.313
184
P-9-13-0
135.468
136.687
137.500
138.313
185
P-9-14-0
135.468
136.687
137.500
138.313
186
P-9-15-0
86.350
87.127
87.645
88.163
187
P-9-16-0
135.468
136.687
137.500
138.313
188
P-9-17-0
134.885
136.099
136.908
137.718
189
Q-5-10-0
176.558
178.147
179.206
180.265
190
Q-5-11-0
132.325
133.516
134.310
135.104
191
Q-5-12-0
GIGI
116.628
117.678
118.377
119.077
192
Q-5-13-0
MEDICAL CHECK-UP
88.632
89.430
89.962
90.493
193
Q-5-14-0
97.524
98.402
98.987
99.572

ASPIRASI
- 449 No
Kode
INA-CBG
194
Q-5-15-0
195
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
67.067
67.671
68.073
68.476
Q-5-16-0
VAKSINASI
75.802
76.484
76.939
77.393
196
Q-5-17-0
PASANG INFUS
65.566
66.157
66.550
66.943
197
Q-5-18-0
123.417
124.527
125.268
126.008
198
Q-5-19-0
137.972
139.214
140.042
140.870
199
Q-5-20-0
ABORSI MENGANCAM
92.478
93.311
93.865
94.420
200
Q-5-21-0
ABORSI
91.219
92.040
92.587
93.134
201
Q-5-22-0
97.524
98.402
98.987
99.572
202
Q-5-23-0
119.395
120.470
121.186
121.903
203
Q-5-24-0
81.545
82.279
82.769
83.258
204
Q-5-25-0
127.168
128.313
129.076
129.839
205
Q-5-26-0
BRONKIAL AKUT
179.998
181.618
182.698
183.778
206
Q-5-27-0
128.095
129.248
130.017
130.785
207
Q-5-28-0
103.946
104.882
105.505
106.129
208
Q-5-29-0

JANTUNG LAIN-LAIN
294.289
296.937
298.703
300.469
209
Q-5-30-0
341.049
344.118
346.164
348.211
210
Q-5-31-0
FRAKTUR
121.672
122.768
123.498
124.228
211
Q-5-32-0
SALURAN KEMIH AKUT
140.924
142.193
143.038
143.884
212
Q-5-33-0
HEMATOLOGI AKUT
147.547
148.875
149.760
150.646
213
Q-5-34-0
INFEKSI VIRUS HIV
209.601
211.487
212.745
214.003
214
Q-5-35-0
INFEKSI AKUT
237.682
239.821
241.247
242.673
215
Q-5-36-0
276.796
279.287
280.948
282.609
216
Q-5-37-0

SHOCK
141.180
142.451
143.298
144.145
217
Q-5-38-0
PARU AKUT
188.268
189.963
191.092
192.222
218
Q-5-39-0
120.478
121.562
122.285
123.008
219
Q-5-40-0
118.208
119.272
119.981
120.690
220
Q-5-41-0
163.642
165.115
166.097
167.079
221
Q-5-42-0
128.302
129.457
130.227
130.996
222
Q-5-43-0
184.762
186.425
187.534
188.642
223
Q-5-44-0
150.792
152.149
153.054
153.958
224
T-2-10-0

TERAPI DETOKSIKASI
78.213
78.917
79.386
79.856
225
U-2-10-0
1.043.842
1.053.236
1.059.499
1.065.762
226
U-2-11-0

LEHER
1.240.722
1.251.889
1.259.333
1.266.777
227
U-2-12-0
136.512
137.740
138.559
139.379
- 450 No
Kode
INA-CBG
228
U-2-13-0
229
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
178.970
180.581
181.655
182.729
U-2-14-0
332.446
335.438
337.432
339.427
230
U-2-15-0
188.888
190.588
191.722
192.855
231
U-2-21-0
220.026
222.006
223.326
224.646
232
U-2-22-0
425.107
428.933
431.484
434.034
233
U-2-23-0
557.028
562.041
565.383
568.725
234
U-2-24-0
469.453
473.678
476.495
479.312
235
U-2-25-0
178.970
180.581
181.655
182.729
236
U-2-31-0
143.820
145.115
145.978
146.840
237
U-2-32-0
178.970
180.581
181.655
182.729
238
U-3-10-0
171.105
172.645
173.672
174.698
239
U-3-11-0
181.660
183.295
184.385
185.475
240
U-3-12-0
80.330
81.053
81.535
82.017
241
U-3-13-0
176.571
178.161
179.220
180.279
242
U-3-14-0
162.233
163.693
164.666
165.640
243
U-3-15-0
141.481
142.755
143.604
144.453
244
U-3-16-0
PROSEDUR PADA GIGI
159.565
161.001
161.959
162.916
245
V-2-10-0

PROSTAT
1.556.744
1.570.755
1.580.096
1.589.436
246
V-2-11-0
PROSEDUR PADA PENIS
175.561
177.141
178.195
179.248
247
V-2-12-0
560.241
565.283
568.644
572.006
248
V-2-13-0
247.396
249.622
251.107
252.591
249
V-2-14-0
247.396
249.622
251.107
252.591
250
V-2-15-0
SIRKUMSISI/SUNAT
135.468
136.687
137.500
138.313
251
V-3-10-0
282.527
285.070
286.765
288.460
597.691
603.070
606.657
610.243
345.063
348.168
350.239
352.309
126.353
127.490
128.248
129.006
322.910
325.816
327.754
329.691
597.691
603.070
606.657
610.243
95.859
96.722
97.297
97.872
1.201.518
1.212.332
1.219.541
1.226.750
252
V-3-11-0
253
V-3-12-0
254
W-2-10-0
255
W-2-11-0
256
W-2-12-0
257
W-2-13-0
258
W-2-21-0

(RHINOPLASTY)

TENGGOROKAN
RONGGA HIDUNG
TENGGOROKAN

SKROTUM
SKROTUM
TRANSURETHRAL

PROSEDUR ABORSI
RAHIM & LEHER RAHIM
TERHALANG/TERGANGGU
TERHALANG/TERGANGGU
PANGGUL TERBUKA
- 451 No
Kode
INA-CBG
259
W-2-22-0
260
W-2-23-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

PANGGUL TERBUKA
126.353
127.490
128.248
129.006
421.644
425.439
427.969
430.499
1.384.131
1.396.588
1.404.892
1.413.197
970.754
979.490
985.315
991.139

JALAN LAHIR
261
W-2-31-0
262
W-2-32-0
263
W-2-33-0
412.583
416.296
418.772
421.247
264
W-2-34-0
140.327
141.590
142.432
143.274
265
W-3-10-0
341.048
344.118
346.164
348.210
266
W-3-11-0
272.624
275.078
276.714
278.349
267
W-3-12-0
126.353
127.490
128.248
129.006
268
Z-3-10-0
1.430.479
1.443.353
1.451.936
1.460.519
269
Z-3-11-0

EMPEDU
1.093.342
1.103.182
1.109.742
1.116.302
270
Z-3-12-0
182.562
184.205
185.300
186.395
271
Z-3-13-0

LAIN-LAIN
1.114.041
1.124.067
1.130.751
1.137.436
272
Z-3-14-0
DIAGNOSTIK TIDUR
220.280
222.263
223.585
224.906
273
Z-3-15-0
143.820
145.115
145.978
146.840
274
Z-3-16-0

(MRI)
461.619
465.774
468.544
471.313
275
Z-3-17-0
PENGOBATAN NUKLIR
193.798
195.542
196.705
197.868
276
Z-3-18-0
CT-SCAN KEPALA
186.720
188.401
189.521
190.642
277
Z-3-19-0
CT SCAN LAIN-LAIN
194.340
196.089
197.255
198.421
278
Z-3-20-0
132.175
133.365
134.158
134.951
279
Z-3-21-0
126.353
127.490
128.248
129.006
280
Z-3-22-0
142.451
143.733
144.588
145.442
281
Z-3-23-0
148.375
149.711
150.601
151.491
282
Z-3-24-0
291.528
294.151
295.901
297.650
283
Z-3-25-0
129.846
131.015
131.794
132.573
284
Z-3-26-0
146.752
148.072
148.953
149.833
285
Z-3-27-0
PERAWATAN LUKA
140.108
141.369
142.210
143.050
286
Z-3-28-0
IMAGING PAYUDARA
143.820
145.115
145.978
146.840
287
Z-3-29-0
IMAGING LAIN-LAIN
414.516
418.247
420.734
423.221
288
Z-3-30-0
FOTOTERAPI
69.955
70.585
71.004
71.424
- 452 B. RUMAH SAKIT KHUSUS KELAS B NON PENDIDIKAN

1. RUMAH SAKIT JIWAKELAS B NON PENDIDIKAN
a. RawatInap
No
Kode
INA-CBG
A-4-10-i
2
3
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
SEPTIKEMIA RINGAN
1.958.974
2.017.743
2.056.923
2.096.102
A-4-10-ii
SEPTIKEMIA SEDANG
3.348.062
3.448.504
3.515.465
3.582.427
A-4-10-iii
SEPTIKEMIA BERAT
3.965.140
4.084.094
4.163.397
4.242.700
5.256.473
5.414.168
5.519.297
5.624.427
8.120.644
8.364.263
8.526.676
8.689.089
13.283.599
13.682.107
13.947.779
14.213.451

RINGAN
SEDANG
A-4-11-i
A-4-11-ii
A-4-11-iii
A-4-12-i
DEMAM RINGAN
1.532.986
1.578.975
1.609.635
1.640.295
A-4-12-ii
DEMAM SEDANG
2.957.526
3.046.251
3.105.402
3.164.552
A-4-12-iii
DEMAM BERAT
3.384.671
3.486.211
3.553.905
3.621.598
10
A-4-13-i
1.916.232
1.973.719
2.012.044
2.050.369
11
A-4-13-ii
2.299.479
2.368.463
2.414.453
2.460.442
12
A-4-13-iii
2.794.745
2.878.587
2.934.482
2.990.377
13
A-4-14-i
1.803.594
1.857.702
1.893.774
1.929.846
14
A-4-14-ii
2.941.659
3.029.908
3.088.741
3.147.575
15
A-4-14-iii
3.282.805
3.381.289
3.446.945
3.512.601
16
A-4-15-i
INFEKSI HIV RINGAN
2.411.056
2.483.387
2.531.609
2.579.830
17
A-4-15-ii
INFEKSI HIV SEDANG
3.449.218
3.552.695
3.621.679
3.690.664
18
A-4-15-iii
INFEKSI HIV BERAT
6.452.523
6.646.099
6.775.149
6.904.200
19
B-1-01-i
25.749.972
26.522.471
27.037.471
27.552.470
20
B-1-01-ii
28.409.104
29.261.377
29.829.559
30.397.741
21
B-1-01-iii
49.835.414
51.330.476
52.327.184
53.323.893
22
B-1-10-i
3.338.397
3.438.548
3.505.316
3.572.084
23
B-1-10-ii
8.507.842
8.763.078
8.933.234
9.103.391
24
B-1-10-iii
19.720.787
20.312.411
20.706.827
21.101.242
25
B-1-11-i
3.039.234
3.130.411
3.191.196
3.251.981
26
B-1-11-ii
7.628.765
7.857.628
8.010.203
8.162.779
27
B-1-11-iii
9.564.578
9.851.515
10.042.807
10.234.099
28
B-1-12-i
6.482.797
6.677.280
6.806.936
6.936.592
29
B-1-12-ii
13.894.219
14.311.045
14.588.930
14.866.814

LAIN-LAIN RINGAN
LAIN-LAIN SEDANG
LAIN-LAIN BERAT

(RINGAN)
(SEDANG)
(BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
- 453 No
Kode
INA-CBG
30
B-1-12-iii
31
B-1-13-i
32
B-1-13-ii
33
B-1-13-iii
34
B-1-14-i
35
B-1-14-ii
36
B-1-14-iii
37
B-4-10-i
38
B-4-10-ii
39
B-4-10-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
16.519.165
17.014.740
17.345.123
17.675.506
4.248.032
4.375.473
4.460.434
4.545.395
6.919.428
7.127.011
7.265.400
7.403.788
10.201.179
10.507.214
10.711.238
10.915.261
5.768.529
5.941.585
6.056.955
6.172.326
6.415.768
6.608.241
6.736.557
6.864.872
10.036.707
10.337.808
10.538.542
10.739.276
1.613.947
1.662.365
1.694.644
1.726.923
2.338.032
2.408.173
2.454.934
2.501.694
3.940.735
4.058.957
4.137.772
4.216.587
3.896.672
4.013.572
4.091.506
4.169.439
5.923.915
6.101.632
6.220.110
6.338.589
6.380.262
6.571.670
6.699.275
6.826.880
3.419.063
3.521.635
3.590.016
3.658.397
4.847.390
4.992.811
5.089.759
5.186.707
9.212.351
9.488.722
9.672.969
9.857.216
2.299.479
2.368.463
2.414.453
2.460.442
3.347.637
3.448.066
3.515.019
3.581.972
5.531.992
5.697.951
5.808.591
5.919.231
2.960.897
3.049.724
3.108.942
3.168.160
3.327.232
3.427.049
3.493.594
3.560.138
4.232.556
4.359.533
4.444.184
4.528.835

LAPAROSKOPIK BERAT
LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT

PANCREAS RINGAN
PANCREAS SEDANG
PANCREAS BERAT
(RINGAN)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT
40
B-4-11-i
41
B-4-11-ii
42
B-4-11-iii
43
B-4-12-i
44
B-4-12-ii
45
B-4-12-iii
46
B-4-13-i
47
B-4-13-ii
48
B-4-13-iii
49
B-4-14-i
50
B-4-14-ii
51
B-4-14-iii
52
C-4-10-i
3.011.991
3.102.351
3.162.591
3.222.831
53
C-4-10-ii
5.851.983
6.027.542
6.144.582
6.261.622
54
C-4-10-iii
LEUKEMIA AKUT BERAT
8.636.093
8.895.176
9.067.898
9.240.620
55
C-4-11-i
3.030.053
3.120.954
3.181.556
3.242.157
56
C-4-11-ii
3.471.893
3.576.050
3.645.487
3.714.925
57
C-4-11-iii
7.011.361
7.221.701
7.361.929
7.502.156
58
C-4-12-i
RADIOTERAPI RINGAN
1.532.986
1.578.975
1.609.635
1.640.295
59
C-4-12-ii
RADIOTERAPI SEDANG
5.677.372
5.847.693
5.961.240
6.074.788
60
C-4-12-iii
RADIOTERAPI BERAT
11.526.202
11.871.988
12.102.512
12.333.036
61
C-4-13-i
KEMOTERAPI RINGAN
1.532.986
1.578.975
1.609.635
1.640.295
- 454 No
Kode
INA-CBG
62
C-4-13-ii
63
C-4-13-iii
64
C-4-14-i
65
C-4-14-ii
66
C-4-14-iii
67
D-1-10-i
68
D-1-10-ii
69
D-1-10-iii
70
D-1-11-i
71
72
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
KEMOTERAPI SEDANG
3.065.972
3.157.951
3.219.270
3.280.590
KEMOTERAPI BERAT
4.011.597
4.131.945
4.212.177
4.292.409
2.673.892
2.754.109
2.807.587
2.861.064
3.907.262
4.024.480
4.102.625
4.180.770
5.956.508
6.135.203
6.254.333
6.373.463
16.477.024
16.971.334
17.300.875
17.630.415
25.095.771
25.848.644
26.350.560
26.852.475
34.011.627
35.031.976
35.712.208
36.392.441
4.510.065
4.645.367
4.735.569
4.825.770
D-1-11-ii
10.325.329
10.635.089
10.841.595
11.048.102
D-1-11-iii
16.184.173
16.669.698
16.993.381
17.317.065
4.130.132
4.254.036
4.336.638
4.419.241
11.374.821
11.716.066
11.943.562
12.171.059
18.069.326
18.611.405
18.972.792
19.334.178

RINGAN
SEDANG
BERAT
TULANG RINGAN
TULANG SEDANG
TULANG BERAT

73
D-1-20-i
74
D-1-20-ii
75
D-1-20-iii
76
D-4-10-i
1.776.526
1.829.821
1.865.352
1.900.882
77
D-4-10-ii
2.973.309
3.062.509
3.121.975
3.181.441
78
D-4-10-iii
4.160.223
4.285.030
4.368.234
4.451.438
79
D-4-11-i
1.916.232
1.973.719
2.012.044
2.050.369
80
D-4-11-ii
4.339.441
4.469.624
4.556.413
4.643.202
81
D-4-11-iii
6.573.649
6.770.858
6.902.331
7.033.804
82
D-4-12-i
1.985.479
2.045.044
2.084.753
2.124.463
83
D-4-12-ii
2.754.055
2.836.676
2.891.757
2.946.839
84
D-4-12-iii
4.228.853
4.355.718
4.440.295
4.524.872
1.532.986
1.578.975
1.609.635
1.640.295
2.299.479
2.368.463
2.414.453
2.460.442
3.177.708
3.273.039
3.336.593
3.400.147
1.916.232
1.973.719
2.012.044
2.050.369
4.312.436
4.441.809
4.528.058
4.614.306
5.144.139
5.298.463
5.401.346
5.504.229
4.942.887
5.091.174
5.190.031
5.288.889
6.474.712
6.668.953
6.798.447
6.927.941
12.833.956
13.218.975
13.475.654
13.732.333
3.782.050
3.895.512
3.971.153
4.046.794
85
D-4-13-i
86
D-4-13-ii
87
D-4-13-iii
88
D-4-14-i
89
D-4-14-ii
90
D-4-14-iii
91
E-1-01-i
92
E-1-01-ii
93
E-1-01-iii
94
E-1-10-i

RINGAN
SEDANG
BERAT
- 455 No
Kode
INA-CBG
95
E-1-10-ii
96
E-1-10-iii
97
E-1-20-i
98
E-1-20-ii
99
E-1-20-iii
100
E-4-10-i
101
E-4-10-ii
102
E-4-10-iii
103
E-4-11-i
104
E-4-11-ii
105
E-4-11-iii
106
E-4-12-i
107
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.590.521
4.728.237
4.820.047
4.911.858
9.675.467
9.965.731
10.159.240
10.352.750
5.832.414
6.007.387
6.124.035
6.240.683
7.811.577
8.045.924
8.202.155
8.358.387
17.308.246
17.827.493
18.173.658
18.519.823
2.393.203
2.464.999
2.512.863
2.560.727
3.665.788
3.775.762
3.849.078
3.922.393
6.217.831
6.404.366
6.528.722
6.653.079
2.199.171
2.265.146
2.309.130
2.353.113
4.160.454
4.285.267
4.368.477
4.451.686
6.860.780
7.066.604
7.203.819
7.341.035
2.107.856
2.171.091
2.213.248
2.255.406
E-4-12-ii
3.449.218
3.552.695
3.621.679
3.690.664
108
E-4-12-iii
5.541.579
5.707.827
5.818.658
5.929.490
109
E-4-13-i
2.771.711
2.854.863
2.910.297
2.965.731
110
E-4-13-ii
4.759.048
4.901.819
4.997.000
5.092.181
111
E-4-13-iii
8.234.355
8.481.385
8.646.072
8.810.759
112
F-4-10-i
SCHIZOFRENIA RINGAN
2.860.492
2.946.306
3.003.516
3.060.726
113
F-4-10-ii
SCHIZOFRENIA SEDANG
3.176.668
3.271.968
3.335.501
3.399.035
114
F-4-10-iii
SCHIZOFRENIA BERAT
4.703.127
4.844.221
4.938.283
5.032.346
115
F-4-11-i
2.636.680
2.715.781
2.768.514
2.821.248
116
F-4-11-ii
3.071.983
3.164.143
3.225.582
3.287.022
117
F-4-11-iii
DEPRESI MAYOR BERAT
3.939.405
4.057.587
4.136.375
4.215.163
118
F-4-12-i
1.447.148
1.490.563
1.519.506
1.548.449
119
F-4-12-ii
2.066.323
2.128.312
2.169.639
2.210.965
120
F-4-12-iii
4.482.540
4.617.016
4.706.667
4.796.318
121
F-4-13-i
2.130.838
2.194.764
2.237.380
2.279.997
122
F-4-13-ii
2.821.778
2.906.431
2.962.867
3.019.302
123
F-4-13-iii
3.638.322
3.747.472
3.820.238
3.893.005
124
F-4-14-i
DEPRESI RINGAN
1.491.587
1.536.335
1.566.166
1.595.998
125
F-4-14-ii
DEPRESI SEDANG
1.913.263
1.970.661
2.008.926
2.047.191
126
F-4-14-iii
DEPRESI BERAT
2.574.380
2.651.612
2.703.099
2.754.587
127
F-4-15-i
1.929.531
1.987.417
2.026.008
2.064.598

RINGAN
SEDANG
BERAT

RINGAN
SEDANG
BERAT

IMPULSE RINGAN
IMPULSE SEDANG
IMPULSE BERAT
- 456 No
Kode
INA-CBG
128
F-4-15-ii
129
F-4-15-iii
130
F-4-16-i
131
F-4-16-ii
132
F-4-16-iii
133
F-4-17-i
134
F-4-17-ii
135
F-4-17-iii
136
F-4-18-i
137
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.894.297
2.981.126
3.039.012
3.096.897
3.811.966
3.926.325
4.002.565
4.078.804
3.819.582
3.934.170
4.010.562
4.086.953
4.440.169
4.573.374
4.662.177
4.750.981
5.926.884
6.104.691
6.223.228
6.341.766
977.686
1.007.016
1.026.570
1.046.124
2.865.503
2.951.468
3.008.779
3.066.089
3.057.281
3.149.000
3.210.145
3.271.291
3.310.685
3.410.006
3.476.220
3.542.433
F-4-18-ii
3.642.689
3.751.970
3.824.823
3.897.677
138
F-4-18-iii
5.615.522
5.783.988
5.896.299
6.008.609
139
F-4-19-i
2.538.983
2.615.153
2.665.932
2.716.712
140
F-4-19-ii
3.251.233
3.348.770
3.413.795
3.478.820
141
F-4-19-iii
4.047.829
4.169.264
4.250.220
4.331.177
7.181.218
7.396.655
7.540.279
7.683.903
12.155.077
12.519.729
12.762.831
13.005.932
23.530.872
24.236.798
24.707.415
25.178.033

RINGAN
SEDANG
BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT
142
G-1-01-i
143
G-1-01-ii
144
G-1-01-iii
145
G-1-10-i
4.772.515
4.915.691
5.011.141
5.106.591
146
G-1-10-ii
6.737.605
6.939.733
7.074.485
7.209.237
147
G-1-10-iii
7.985.501
8.225.066
8.384.776
8.544.486
148
G-1-11-i
5.505.239
5.670.396
5.780.501
5.890.605
149
G-1-11-ii
11.305.422
11.644.585
11.870.694
12.096.802
150
G-1-11-iii
20.650.658
21.270.178
21.683.191
22.096.204
4.281.454
4.409.897
4.495.526
4.581.156
9.292.796
9.571.580
9.757.436
9.943.292
13.739.952
14.152.151
14.426.950
14.701.749

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT
151
G-1-12-i
152
G-1-12-ii
153
G-1-12-iii
154
G-1-13-i
847.907
873.344
890.302
907.260
155
G-1-13-ii
2.277.384
2.345.705
2.391.253
2.436.801
156
G-1-13-iii
5.138.737
5.292.899
5.395.674
5.498.448
5.394.996
5.556.846
5.664.746
5.772.645
7.288.816
7.507.481
7.653.257
7.799.033
17.845.809
18.381.183
18.738.100
19.095.016
6.880.832
7.087.256
7.224.873
7.362.490
157
G-1-20-i
158
G-1-20-ii
159
G-1-20-iii
160
G-1-30-i

RINGAN
SEDANG
BERAT
- 457 No
Kode
INA-CBG
161
G-1-30-ii
162
G-1-30-iii
163
G-4-10-i
164
G-4-10-ii
165
G-4-10-iii
166
G-4-11-i
167
G-4-11-ii
168
G-4-11-iii
169
G-4-12-i
170
G-4-12-ii
171
G-4-12-iii
172
G-4-13-i
173
G-4-13-ii
174
G-4-13-iii
175
G-4-14-i
176
G-4-14-ii
177
G-4-14-iii
178
G-4-15-i
179
G-4-15-ii
180
G-4-15-iii
181
G-4-16-i
182
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
17.959.630
18.498.419
18.857.612
19.216.804
23.119.594
23.813.182
24.275.574
24.737.965
2.299.479
2.368.463
2.414.453
2.460.442
3.144.671
3.239.011
3.301.904
3.364.798
5.512.849
5.678.234
5.788.491
5.898.748
5.103.285
5.256.384
5.358.449
5.460.515
5.919.811
6.097.405
6.215.801
6.334.197
8.675.585
8.935.852
9.109.364
9.282.875
3.816.808
3.931.312
4.007.648
4.083.985
4.809.178
4.953.453
5.049.637
5.145.821
6.984.759
7.194.301
7.333.997
7.473.692
2.123.646
2.187.356
2.229.829
2.272.302
2.950.675
3.039.196
3.098.209
3.157.223
3.444.232
3.547.559
3.616.443
3.685.328
3.883.833
4.000.348
4.078.024
4.155.701
6.390.215
6.581.922
6.709.726
6.837.531
8.000.695
8.240.716
8.400.730
8.560.744
2.571.885
2.649.042
2.700.480
2.751.917
3.193.827
3.289.642
3.353.518
3.417.395
4.706.550
4.847.747
4.941.878
5.036.009
2.146.285
2.210.673
2.253.599
2.296.525
G-4-16-ii
3.105.355
3.198.516
3.260.623
3.322.730
183
G-4-16-iii
5.463.933
5.627.850
5.737.129
5.846.408
184
G-4-17-i
3.683.524
3.794.030
3.867.700
3.941.371
185
G-4-17-ii
4.571.416
4.708.558
4.799.986
4.891.415
186
G-4-17-iii
7.661.730
7.891.582
8.044.817
8.198.051
187
G-4-18-i
2.318.909
2.388.476
2.434.854
2.481.232
188
G-4-18-ii
4.434.876
4.567.922
4.656.620
4.745.317
189
G-4-18-iii
4.698.299
4.839.248
4.933.214
5.027.180
190
G-4-19-i
2.576.152
2.653.437
2.704.960
2.756.483

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
DEGENERATIF RINGAN
DEGENERATIF SEDANG
DEGENERATIF BERAT
RINGAN
SEDANG
BERAT
TRAUMATIK RINGAN
TRAUMATIK SEDANG
TRAUMATIK BERAT
DENGAN INFARK BERAT
TANPA INFARK RINGAN
TANPA INFARK SEDANG
TANPA INFARK BERAT

PERIFER RINGAN
PERIFER SEDANG
PERIFER BERAT
PERSARAFAN RINGAN
PERSARAFAN SEDANG
PERSARAFAN BERAT
RINGAN
- 458 No
Kode
INA-CBG
191
G-4-19-ii
192
G-4-19-iii
193
G-4-20-i
194
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.563.229
4.700.125
4.791.390
4.882.655
6.491.903
6.686.660
6.816.498
6.946.337
1.512.850
1.558.235
1.588.492
1.618.749
G-4-20-ii
2.081.895
2.144.352
2.185.990
2.227.628
195
G-4-20-iii
3.438.705
3.541.866
3.610.640
3.679.414
196
G-4-21-i
2.090.736
2.153.458
2.195.273
2.237.088
197
G-4-21-ii
2.906.124
2.993.307
3.051.430
3.109.552
198
G-4-21-iii
5.101.397
5.254.439
5.356.467
5.458.495
199
G-4-22-i
1.532.986
1.578.975
1.609.635
1.640.295
200
G-4-22-ii
1.916.232
1.973.719
2.012.044
2.050.369
201
G-4-22-iii
2.198.419
2.264.372
2.308.340
2.352.309
202
G-4-23-i
1.885.561
1.942.128
1.979.839
2.017.550
203
G-4-23-ii
1.961.445
2.020.289
2.059.517
2.098.746
204
G-4-23-iii
2.792.616
2.876.394
2.932.247
2.988.099
205
G-4-24-i
1.578.633
1.625.992
1.657.564
1.689.137
206
G-4-24-ii
2.288.401
2.357.053
2.402.821
2.448.589
207
G-4-24-iii
TRAUMA KEPALA BERAT
4.420.172
4.552.777
4.641.181
4.729.584
208
G-4-25-i
GEGAR OTAK RINGAN
1.532.986
1.578.975
1.609.635
1.640.295
209
G-4-25-ii
GEGAR OTAK SEDANG
1.916.232
1.973.719
2.012.044
2.050.369
210
G-4-25-iii
GEGAR OTAK BERAT
2.392.780
2.464.564
2.512.419
2.560.275
211
G-4-26-i
3.107.471
3.200.695
3.262.844
3.324.994
212
G-4-26-ii
3.523.976
3.629.695
3.700.174
3.770.654
213
G-4-26-iii
5.172.505
5.327.680
5.431.130
5.534.580
214
H-1-20-i
2.963.935
3.052.853
3.112.131
3.171.410
215
H-1-20-ii
5.405.070
5.567.222
5.675.324
5.783.425
216
H-1-20-iii
7.350.558
7.571.074
7.718.085
7.865.097
217
H-1-30-i
2.901.974
2.989.033
3.047.073
3.105.112
218
H-1-30-ii
3.308.251
3.407.498
3.473.663
3.539.828
219
H-1-30-iii
5.519.696
5.685.287
5.795.681
5.906.075
220
H-4-10-i
2.628.703
2.707.564
2.760.138
2.812.712
221
H-4-10-ii
4.279.587
4.407.975
4.493.567
4.579.159
222
H-4-10-iii
6.719.492
6.921.077
7.055.467
7.189.856
223
H-4-11-i
2.106.017
2.169.197
2.211.317
2.253.438

SEDANG

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
RINGAN
SEDANG
RINGAN
SEDANG
- 459 No
Kode
INA-CBG
224
H-4-11-ii
225
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.324.638
2.394.377
2.440.870
2.487.363
H-4-11-iii
3.084.300
3.176.829
3.238.515
3.300.201
226
H-4-12-i
2.922.014
3.009.674
3.068.114
3.126.555
227
H-4-12-ii
3.958.059
4.076.801
4.155.962
4.235.123
228
H-4-12-iii
6.603.751
6.801.864
6.933.939
7.066.014
229
I-1-01-i
33.405.303
34.407.462
35.075.569
35.743.675
230
I-1-01-ii
34.140.394
35.164.606
35.847.414
36.530.222
231
I-1-01-iii
53.889.957
55.506.656
56.584.455
57.662.254
232
I-1-02-i
18.533.070
19.089.062
19.459.723
19.830.385
233
I-1-02-ii
23.907.660
24.624.890
25.103.043
25.581.196
234
I-1-02-iii
29.467.581
30.351.609
30.940.960
31.530.312
235
I-1-03-i
11.299.561
11.638.548
11.864.539
12.090.530
236
I-1-03-ii
15.487.993
15.952.633
16.262.393
16.572.153
237
I-1-03-iii
22.715.724
23.397.195
23.851.510
24.305.824
238
I-1-04-i
18.542.415
19.098.687
19.469.535
19.840.384
239
I-1-04-ii
23.818.061
24.532.603
25.008.964
25.485.325
240
I-1-04-iii
50.775.161
52.298.415
53.313.919
54.329.422
241
I-1-05-i
24.529.063
25.264.935
25.755.516
26.246.097
242
I-1-05-ii
29.434.876
30.317.922
30.906.619
31.495.317
243
I-1-05-iii
40.502.203
41.717.269
42.527.313
43.337.357
244
I-1-06-i
15.397.665
15.859.595
16.167.548
16.475.501
245
I-1-06-ii
20.148.910
20.753.377
21.156.356
21.559.334
246
I-1-06-iii
22.241.100
22.908.333
23.353.155
23.797.977
20.249.095
20.856.568
21.261.550
21.666.532
24.981.372
25.730.813
26.230.441
26.730.068
27.254.515
28.072.150
28.617.240
29.162.331
3.851.872
3.967.428
4.044.465
4.121.503
4.282.896
4.411.383
4.497.041
4.582.699
247
I-1-07-i
248
I-1-07-ii
249
I-1-07-iii
250
I-1-11-i
251
I-1-11-ii

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
KATETERISASI RINGAN
KATETERISASI SEDANG
KATETERISASI BERAT
RINGAN
SEDANG
RINGAN
SEDANG
BERAT

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
RINGAN
SEDANG
- 460 No
Kode
INA-CBG
252
I-1-11-iii
253
I-1-12-i
254
I-1-12-ii
255
I-1-12-iii
256
I-1-13-i
257
I-1-13-ii
258
I-1-13-iii
259
I-1-14-i
260
I-1-14-ii
261
I-1-14-iii
262
I-1-15-i
263
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.699.229
5.870.206
5.984.191
6.098.175
9.845.958
10.141.337
10.338.256
10.535.175
13.281.517
13.679.962
13.945.593
14.211.223
18.137.291
18.681.410
19.044.156
19.406.901
6.014.556
6.194.993
6.315.284
6.435.575
6.762.842
6.965.727
7.100.984
7.236.241
14.727.990
15.169.829
15.464.389
15.758.949
19.078.160
19.650.505
20.032.068
20.413.631
23.711.428
24.422.770
24.896.999
25.371.228
31.070.147
32.002.251
32.623.654
33.245.057
6.071.237
6.253.374
6.374.799
6.496.224
I-1-15-ii
11.122.924
11.456.612
11.679.070
11.901.529
264
I-1-15-iii
19.193.218
19.769.015
20.152.879
20.536.743
265
I-1-16-i
8.176.354
8.421.645
8.585.172
8.748.699
266
I-1-16-ii
21.258.521
21.896.277
22.321.447
22.746.618
267
I-1-16-iii
24.521.183
25.256.818
25.747.242
26.237.665
268
I-1-17-i
3.492.001
3.596.761
3.666.601
3.736.441
269
I-1-17-ii
7.233.199
7.450.195
7.594.859
7.739.523
270
I-1-17-iii
41.933.689
43.191.699
44.030.373
44.869.047
271
I-1-20-i
5.517.259
5.682.776
5.793.122
5.903.467
272
I-1-20-ii
9.292.796
9.571.580
9.757.436
9.943.292
273
I-1-20-iii
17.912.119
18.449.482
18.807.725
19.165.967
274
I-1-30-i
9.276.116
9.554.400
9.739.922
9.925.445
275
I-1-30-ii
19.296.196
19.875.082
20.261.006
20.646.930
276
I-1-30-iii
29.902.096
30.799.159
31.397.201
31.995.243
277
I-1-40-i
16.611.943
17.110.301
17.442.540
17.774.779
278
I-1-40-ii
21.413.420
22.055.823
22.484.091
22.912.359
279
I-1-40-iii
25.753.517
26.526.122
27.041.192
27.556.263

BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

DARAH VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
- 461 No
Kode
INA-CBG
280
I-4-10-i
281
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.831.236
4.976.173
5.072.797
5.169.422
I-4-10-ii
7.628.608
7.857.466
8.010.038
8.162.610
282
I-4-10-iii
11.004.932
11.335.080
11.555.179
11.775.278
283
I-4-11-i
4.940.498
5.088.713
5.187.523
5.286.333
284
I-4-11-ii
5.748.697
5.921.158
6.036.132
6.151.106
285
I-4-11-iii
9.327.246
9.607.063
9.793.608
9.980.153
286
I-4-12-i
5.017.643
5.168.172
5.268.525
5.368.878
287
I-4-12-ii
7.160.162
7.374.966
7.518.170
7.661.373
288
I-4-12-iii
8.686.283
8.946.872
9.120.597
9.294.323
4.507.222
4.642.439
4.732.583
4.822.728
6.548.074
6.744.516
6.875.478
7.006.439
10.776.448
11.099.742
11.315.271
11.530.800

VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
289
I-4-13-i
290
I-4-13-ii
291
I-4-13-iii
292
I-4-14-i
2.803.076
2.887.168
2.943.230
2.999.291
293
I-4-14-ii
3.280.013
3.378.414
3.444.014
3.509.614
294
I-4-14-iii
5.082.930
5.235.417
5.337.076
5.438.735
3.065.972
3.157.951
3.219.270
3.280.590
5.903.776
6.080.889
6.198.965
6.317.040
6.728.884
6.930.750
7.065.328
7.199.906

295
I-4-15-i
296
I-4-15-ii
297
I-4-15-iii
298
I-4-16-i
2.387.213
2.458.829
2.506.573
2.554.317
299
I-4-16-ii
3.828.766
3.943.629
4.020.204
4.096.779
300
I-4-16-iii
4.806.785
4.950.988
5.047.124
5.143.260
301
I-4-17-i
HIPERTENSI RINGAN
2.768.202
2.851.248
2.906.612
2.961.976
302
I-4-17-ii
HIPERTENSI SEDANG
3.776.331
3.889.621
3.965.147
4.040.674
303
I-4-17-iii
HIPERTENSI BERAT
4.413.773
4.546.186
4.634.461
4.722.737
4.076.766
4.199.069
4.280.604
4.362.139
6.245.333
6.432.692
6.557.599
6.682.506
8.419.709
8.672.300
8.840.695
9.009.089
3.190.604
3.286.322
3.350.134
3.413.946
5.179.483
5.334.867
5.438.457
5.542.047
5.932.933
6.110.921
6.229.579
6.348.238

RINGAN
SEDANG
KONGENITAL BERAT
RINGAN
SEDANG
BERAT
304
I-4-18-i
305
I-4-18-ii
306
I-4-18-iii
307
I-4-19-i
308
I-4-19-ii
309
I-4-19-iii
310
I-4-20-i
3.872.250
3.988.417
4.065.862
4.143.307
311
I-4-20-ii
4.461.121
4.594.954
4.684.177
4.773.399
312
I-4-20-iii
5.920.650
6.098.269
6.216.682
6.335.095
- 462 No
Kode
INA-CBG
313
I-4-21-i
314
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.149.465
5.303.949
5.406.938
5.509.928
I-4-21-ii
6.423.624
6.616.332
6.744.805
6.873.277
315
I-4-21-iii
8.763.185
9.026.080
9.201.344
9.376.608
316
I-4-22-i
2.491.102
2.565.835
2.615.657
2.665.479
317
I-4-22-ii
2.870.495
2.956.610
3.014.020
3.071.430
318
I-4-22-iii
4.187.975
4.313.614
4.397.373
4.481.133
1.906.150
1.963.335
2.001.458
2.039.581
2.340.313
2.410.522
2.457.329
2.504.135
4.572.758
4.709.941
4.801.396
4.892.851
3.027.590
3.118.418
3.178.970
3.239.522
7.559.056
7.785.827
7.937.009
8.088.190
9.557.061
9.843.772
10.034.914
10.226.055
24.392.366
25.124.137
25.611.985
26.099.832
26.058.276
26.840.025
27.361.190
27.882.356
44.520.718
45.856.340
46.746.754
47.637.169
12.468.894
12.842.961
13.092.339
13.341.716
13.357.508
13.758.233
14.025.383
14.292.533
19.738.590
20.330.748
20.725.520
21.120.291
4.865.543
5.011.509
5.108.820
5.206.131
11.752.054
12.104.615
12.339.656
12.574.698
17.770.074
18.303.176
18.658.577
19.013.979
4.130.132
4.254.036
4.336.638
4.419.241
6.116.401
6.299.894
6.422.222
6.544.550
8.025.239
8.265.996
8.426.501
8.587.006
2.835.924
2.921.001
2.977.720
3.034.438
12.170.050
12.535.152
12.778.553
13.021.954
33.195.028
34.190.878
34.854.779
35.518.679

RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
319
I-4-23-i
320
I-4-23-ii
321
I-4-23-iii
322
I-4-24-i
323
I-4-24-ii
324
I-4-24-iii
325
J-1-01-i
326
J-1-01-ii
327
J-1-01-iii
328
J-1-02-i
329
J-1-02-ii
330
J-1-02-iii
331
J-1-10-i
332
J-1-10-ii
333
J-1-10-iii
334
J-1-20-i
335
J-1-20-ii
336
J-1-20-iii
337
J-1-30-i
338
J-1-30-ii
339
J-1-30-iii
340
J-4-10-i
2.457.796
2.531.530
2.580.686
2.629.842
341
J-4-10-ii
3.514.353
3.619.784
3.690.071
3.760.358
342
J-4-10-iii
5.316.692
5.476.193
5.582.526
5.688.860
343
J-4-11-i
2.064.869
2.126.815
2.168.112
2.209.409
- 463 No
Kode
INA-CBG
344
J-4-11-ii
345
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.874.250
2.960.477
3.017.962
3.075.447
J-4-11-iii
4.118.873
4.242.440
4.324.817
4.407.194
346
J-4-12-i
EMBOLI PARU RINGAN
2.371.204
2.442.340
2.489.764
2.537.188
347
J-4-12-ii
EMBOLI PARU SEDANG
3.070.628
3.162.747
3.224.159
3.285.572
348
J-4-12-iii
EMBOLI PARU BERAT
4.100.513
4.223.529
4.305.539
4.387.549
349
J-4-13-i
4.864.088
5.010.011
5.107.293
5.204.574
350
J-4-13-ii
7.150.210
7.364.716
7.507.720
7.650.724
351
J-4-13-iii
11.625.171
11.973.926
12.206.429
12.438.933
352
J-4-14-i
TUMOR PARU RINGAN
3.314.722
3.414.164
3.480.459
3.546.753
353
J-4-14-ii
TUMOR PARU SEDANG
5.552.614
5.719.192
5.830.244
5.941.297
354
J-4-14-iii
TUMOR PARU BERAT
6.601.775
6.799.829
6.931.864
7.063.900
355
J-4-15-i
2.901.913
2.988.971
3.047.009
3.105.047
356
J-4-15-ii
4.086.066
4.208.648
4.290.370
4.372.091
357
J-4-15-iii
5.134.665
5.288.705
5.391.399
5.494.092
358
J-4-16-i
1.982.198
2.041.664
2.081.307
2.120.951
359
J-4-16-ii
3.411.456
3.513.799
3.582.028
3.650.257
360
J-4-16-iii
5.589.797
5.757.491
5.869.287
5.981.083
361
J-4-17-i
2.375.778
2.447.052
2.494.567
2.542.083
362
J-4-17-ii
3.224.621
3.321.359
3.385.852
3.450.344
363
J-4-17-iii
5.172.012
5.327.172
5.430.613
5.534.053
364
J-4-18-i
1.610.153
1.658.457
1.690.660
1.722.863
365
J-4-18-ii
2.463.533
2.537.439
2.586.710
2.635.981
366
J-4-18-iii
2.576.244
2.653.531
2.705.056
2.756.581
367
J-4-19-i
3.010.701
3.101.022
3.161.236
3.221.450
368
J-4-19-ii
4.086.036
4.208.617
4.290.338
4.372.059
369
J-4-19-iii
5.840.759
6.015.982
6.132.797
6.249.612
370
J-4-20-i
3.323.435
3.423.138
3.489.607
3.556.076
371
J-4-20-ii
4.401.752
4.533.805
4.621.840
4.709.875
372
J-4-20-iii
8.773.870
9.037.086
9.212.563
9.388.040
373
J-4-21-i
1.849.900
1.905.397
1.942.395
1.979.393
374
J-4-21-ii
4.121.715
4.245.366
4.327.800
4.410.235
375
J-4-21-iii
5.750.384
5.922.896
6.037.903
6.152.911
376
K-1-10-i
4.130.132
4.254.036
4.336.638
4.419.241

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT

USUS BESAR (RINGAN)
- 464 No
Kode
INA-CBG
377
K-1-10-ii
378
K-1-10-iii
379
K-1-11-i
380
K-1-11-ii
381
K-1-11-iii
382
K-1-12-i
383
K-1-12-ii
384
K-1-12-iii
385
K-1-13-i
386
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
7.752.995
7.985.585
8.140.645
8.295.704
9.080.092
9.352.495
9.534.096
9.715.698
4.776.832
4.920.137
5.015.674
5.111.210
6.271.404
6.459.546
6.584.974
6.710.402
15.915.589
16.393.057
16.711.369
17.029.681
2.569.570
2.646.657
2.698.049
2.749.440
3.348.945
3.449.413
3.516.392
3.583.371
6.661.755
6.861.608
6.994.843
7.128.078
2.918.679
3.006.240
3.064.613
3.122.987
K-1-13-ii
5.098.095
5.251.038
5.352.999
5.454.961
387
K-1-13-iii
5.452.228
5.615.795
5.724.840
5.833.884
388
K-1-14-i
4.716.759
4.858.261
4.952.597
5.046.932
389
K-1-14-ii
5.540.367
5.706.578
5.817.386
5.928.193
390
K-1-14-iii
13.072.785
13.464.969
13.726.425
13.987.880
391
K-1-20-i
9.151.896
9.426.452
9.609.490
9.792.528
392
K-1-20-ii
12.773.633
13.156.842
13.412.314
13.667.787
393
K-1-20-iii
26.173.143
26.958.337
27.481.800
28.005.263
394
K-1-30-i
6.024.233
6.204.960
6.325.445
6.445.929
395
K-1-30-ii
8.260.263
8.508.071
8.673.276
8.838.482
396
K-1-30-iii
17.303.800
17.822.914
18.168.990
18.515.066
397
K-1-40-i
6.052.069
6.233.632
6.354.673
6.475.714
398
K-1-40-ii
6.659.701
6.859.492
6.992.686
7.125.880
399
K-1-40-iii
11.044.473
11.375.807
11.596.697
11.817.586
400
K-1-50-i
4.616.269
4.754.757
4.847.082
4.939.408
401
K-1-50-ii
5.978.286
6.157.634
6.277.200
6.396.766
402
K-1-50-iii
PROSEDUR ANAL BERAT
8.487.576
8.742.203
8.911.955
9.081.706
403
K-4-10-i
3.496.492
3.601.386
3.671.316
3.741.246
404
K-4-10-ii
4.183.757
4.309.270
4.392.945
4.476.620
405
K-4-10-iii
14.096.568
14.519.465
14.801.396
15.083.328
406
K-4-11-i
1.727.329
1.779.149
1.813.695
1.848.242
407
K-4-11-ii
2.803.360
2.887.461
2.943.528
2.999.595
408
K-4-11-iii
4.701.785
4.842.839
4.936.874
5.030.910
409
K-4-12-i
1.763.610
1.816.518
1.851.790
1.887.063

USUS BESAR (SEDANG)
USUS BESAR (BERAT)
RINGAN
SEDANG

RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
- 465 No
Kode
INA-CBG
410
K-4-12-ii
411
K-4-12-iii
412
K-4-13-i
413
K-4-13-ii
414
K-4-13-iii
415
K-4-14-i
416
K-4-14-ii
417
K-4-14-iii
418
K-4-15-i
419
K-4-15-ii
420
K-4-15-iii
421
K-4-16-i
422
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.080.630
3.173.049
3.234.662
3.296.274
6.777.517
6.980.842
7.116.393
7.251.943
2.425.848
2.498.624
2.547.141
2.595.658
3.111.596
3.204.944
3.267.176
3.329.408
5.023.607
5.174.316
5.274.788
5.375.260
1.998.030
2.057.971
2.097.932
2.137.892
2.682.036
2.762.497
2.816.138
2.869.779
4.708.802
4.850.066
4.944.242
5.038.418
2.110.232
2.173.539
2.215.744
2.257.949
3.814.022
3.928.443
4.004.723
4.081.004
5.352.797
5.513.381
5.620.437
5.727.493
2.121.522
2.185.168
2.227.598
2.270.029
K-4-16-ii
2.809.372
2.893.653
2.949.840
3.006.028
423
K-4-16-iii
3.775.450
3.888.714
3.964.223
4.039.732
424
K-4-17-i
1.532.986
1.578.975
1.609.635
1.640.295
425
K-4-17-ii
3.008.530
3.098.786
3.158.956
3.219.127
426
K-4-17-iii
3.657.328
3.767.048
3.840.194
3.913.341
427
K-4-18-i
2.055.307
2.116.966
2.158.072
2.199.178
428
K-4-18-ii
3.201.115
3.297.148
3.361.171
3.425.193
429
K-4-18-iii
3.722.157
3.833.821
3.908.264
3.982.708
430
L-1-20-i
21.101.199
21.734.235
22.156.259
22.578.283
431
L-1-20-ii
21.733.020
22.385.011
22.819.671
23.254.332
432
L-1-20-iii
30.459.720
31.373.512
31.982.706
32.591.901
433
L-1-30-i
7.227.730
7.444.562
7.589.117
7.733.671
434
L-1-30-ii
13.863.454
14.279.358
14.556.627
14.833.896
435
L-1-30-iii
14.621.618
15.060.267
15.352.699
15.645.132
436
L-1-40-i
3.864.444
3.980.377
4.057.666
4.134.955
437
L-1-40-ii
8.260.263
8.508.071
8.673.276
8.838.482
438
L-1-40-iii
11.849.688
12.205.179
12.442.173
12.679.167
439
L-1-50-i
5.162.664
5.317.544
5.420.798
5.524.051
440
L-1-50-ii
9.292.796
9.571.580
9.757.436
9.943.292

(RINGAN)
(SEDANG)
RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
- 466 No
Kode
INA-CBG
441
L-1-50-iii
442
L-4-10-i
443
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
11.236.305
11.573.394
11.798.120
12.022.847
2.547.984
2.624.424
2.675.383
2.726.343
L-4-10-ii
3.546.832
3.653.237
3.724.173
3.795.110
444
L-4-10-iii
7.299.768
7.518.761
7.664.757
7.810.752
445
L-4-11-i
2.925.447
3.013.211
3.071.720
3.130.228
446
L-4-11-ii
4.007.811
4.128.046
4.208.202
4.288.358
447
L-4-11-iii
10.868.684
11.194.744
11.412.118
11.629.491
448
L-4-12-i
2.887.932
2.974.570
3.032.328
3.090.087
449
L-4-12-ii
4.538.199
4.674.345
4.765.109
4.855.873
450
L-4-12-iii
7.349.451
7.569.934
7.716.923
7.863.912
451
L-4-13-i
1.941.404
1.999.646
2.038.474
2.077.303
452
L-4-13-ii
2.238.554
2.305.710
2.350.481
2.395.252
453
L-4-13-iii
3.358.005
3.458.745
3.525.905
3.593.065
454
L-4-14-i
1.769.207
1.822.283
1.857.667
1.893.051
455
L-4-14-ii
2.629.497
2.708.382
2.760.972
2.813.562
456
L-4-14-iii
4.836.015
4.981.095
5.077.816
5.174.536
457
M-1-01-i
7.549.150
7.775.625
7.926.608
8.077.591
458
M-1-01-ii
8.426.073
8.678.855
8.847.376
9.015.898
459
M-1-01-iii
11.836.349
12.191.440
12.428.167
12.664.894
460
M-1-02-i
7.120.205
7.333.811
7.476.215
7.618.619
461
M-1-02-ii
11.690.023
12.040.723
12.274.524
12.508.324
462
M-1-02-iii
20.086.808
20.689.412
21.091.149
21.492.885
463
M-1-03-i
13.422.928
13.825.615
14.094.074
14.362.533
464
M-1-03-ii
15.708.751
16.180.013
16.494.188
16.808.363
465
M-1-03-iii
20.443.229
21.056.525
21.465.390
21.874.255
466
M-1-04-i
4.696.986
4.837.895
4.931.835
5.025.775
467
M-1-04-ii
6.021.487
6.202.132
6.322.561
6.442.991
468
M-1-04-iii
7.534.756
7.760.799
7.911.494
8.062.189
469
M-1-05-i
7.317.002
7.536.512
7.682.852
7.829.192
470
M-1-05-ii
8.456.493
8.710.188
8.879.318
9.048.448
471
M-1-05-iii
14.403.711
14.835.823
15.123.897
15.411.971
472
M-1-07-i
6.065.162
6.247.117
6.368.420
6.489.724


- 467 No
Kode
INA-CBG
473
M-1-07-ii
474
M-1-07-iii
475
M-1-10-i
476
M-1-10-ii
477
M-1-10-iii
478
M-1-20-i
479
M-1-20-ii
480
M-1-20-iii
481
M-1-30-i
482
M-1-30-ii
483
M-1-30-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
8.125.422
8.369.185
8.531.693
8.694.202
16.552.255
17.048.823
17.379.868
17.710.913
5.047.936
5.199.374
5.300.333
5.401.291
18.750.794
19.313.318
19.688.334
20.063.350
21.862.083
22.517.945
22.955.187
23.392.428
4.993.713
5.143.524
5.243.398
5.343.273
7.128.077
7.341.919
7.484.481
7.627.042
13.855.427
14.271.090
14.548.199
14.825.307
2.986.987
3.076.596
3.136.336
3.196.076
6.171.874
6.357.031
6.480.468
6.603.906
PROSEDUR KAKI BERAT
9.207.135
9.483.349
9.667.492
9.851.635
2.949.651
3.038.140
3.097.133
3.156.126
4.854.991
5.000.640
5.097.740
5.194.840
7.227.730
7.444.562
7.589.117
7.733.671

TULANG WAJAH RINGAN
TULANG WAJAH SEDANG
TULANG WAJAH BERAT

RINGAN
SEDANG
BERAT
484
M-1-40-i
485
M-1-40-ii
486
M-1-40-iii
487
M-1-50-i
3.997.117
4.117.030
4.196.973
4.276.915
488
M-1-50-ii
7.227.730
7.444.562
7.589.117
7.733.671
489
M-1-50-iii
8.260.263
8.508.071
8.673.276
8.838.482
490
M-1-60-i
3.016.562
3.107.059
3.167.390
3.227.721
491
M-1-60-ii
6.039.177
6.220.352
6.341.136
6.461.919
492
M-1-60-iii
10.510.304
10.825.613
11.035.819
11.246.025
493
M-1-70-i
4.040.980
4.162.210
4.243.029
4.323.849
494
M-1-70-ii
8.245.601
8.492.969
8.657.881
8.822.793
495
M-1-70-iii
13.292.905
13.691.692
13.957.550
14.223.408
496
M-1-80-i
3.255.936
3.353.615
3.418.733
3.483.852
497
M-1-80-ii
4.922.310
5.069.979
5.168.426
5.266.872
498
M-1-80-iii
11.332.433
11.672.406
11.899.055
12.125.703
499
M-4-10-i
1.753.464
1.806.068
1.841.137
1.876.206
500
M-4-10-ii
3.146.129
3.240.513
3.303.436
3.366.358
501
M-4-10-iii
FRAKTUR FEMUR BERAT
6.680.639
6.881.058
7.014.671
7.148.284
M-4-11-i

PANGGUL RINGAN
2.728.982
2.810.852
2.865.431
2.920.011
502

(RINGAN)
(SEDANG)
SELAIN KAKI (BERAT)
- 468 No
Kode
INA-CBG
503
M-4-11-ii
504
M-4-11-iii
505
M-4-12-i
506
M-4-12-ii
507
M-4-12-iii
508
M-4-13-i
509
M-4-13-ii
510
M-4-13-iii
511
M-4-14-i
512
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
6.260.692
6.448.513
6.573.727
6.698.941
11.112.582
11.445.959
11.668.211
11.890.463
1.532.986
1.578.975
1.609.635
1.640.295
2.789.266
2.872.944
2.928.729
2.984.515
6.131.944
6.315.902
6.438.541
6.561.180
3.806.676
3.920.877
3.997.010
4.073.144
4.261.598
4.389.446
4.474.678
4.559.910
11.323.908
11.663.626
11.890.104
12.116.582
3.065.972
3.157.951
3.219.270
3.280.590
M-4-14-ii
5.354.117
5.514.741
5.621.823
5.728.905
513
M-4-14-iii
OSTEOMIELITIS BERAT
6.948.972
7.157.441
7.296.421
7.435.400
514
M-4-15-i
2.572.963
2.650.152
2.701.612
2.753.071
515
M-4-15-ii
3.192.318
3.288.087
3.351.934
3.415.780
516
M-4-15-iii
7.177.065
7.392.377
7.535.918
7.679.459
517
M-4-16-i
2.570.478
2.647.592
2.699.002
2.750.411
518
M-4-16-ii
3.756.272
3.868.960
3.944.085
4.019.211
519
M-4-16-iii
7.668.368
7.898.419
8.051.787
8.205.154
520
M-4-17-i
2.202.232
2.268.299
2.312.343
2.356.388
521
M-4-17-ii
2.888.099
2.974.742
3.032.504
3.090.266
522
M-4-17-iii
3.962.652
4.081.532
4.160.785
4.240.038
523
M-4-18-i
3.021.264
3.111.902
3.172.327
3.232.752
524
M-4-18-ii
3.720.606
3.832.224
3.906.637
3.981.049
525
M-4-18-iii
5.123.887
5.277.604
5.380.082
5.482.559
526
M-4-19-i
2.246.351
2.313.741
2.358.668
2.403.595
527
M-4-19-ii
3.595.866
3.703.742
3.775.659
3.847.576
528
M-4-19-iii
5.737.915
5.910.053
6.024.811
6.139.569
529
M-4-20-i
1.674.677
1.724.917
1.758.410
1.791.904
530
M-4-20-ii
2.299.479
2.368.463
2.414.453
2.460.442
531
M-4-20-iii
2.548.365
2.624.815
2.675.783
2.726.750
532
M-4-21-i
1.604.752
1.652.895
1.684.990
1.717.085

PANGGUL SEDANG
PANGGUL BERAT
PELVIS RINGAN
PELVIS SEDANG
PELVIS BERAT

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
RINGAN
SEDANG
BERAT
ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
(RINGAN)
(SEDANG)
(RINGAN)
- 469 No
Kode
INA-CBG
533
M-4-21-ii
534
M-4-21-iii
535
N-1-01-i
536
N-1-01-ii
537
N-1-01-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.691.459
2.772.202
2.826.031
2.879.861
5.557.074
5.723.786
5.834.928
5.946.069
4.189.605
4.315.293
4.399.086
4.482.878
5.666.346
5.836.337
5.949.664
6.062.991
12.014.340
12.374.771
12.615.057
12.855.344
7.227.730
7.444.562
7.589.117
7.733.671
10.410.076
10.722.378
10.930.580
11.138.781
16.520.526
17.016.142
17.346.553
17.676.963
3.097.599
3.190.527
3.252.479
3.314.431
9.693.270
9.984.068
10.177.934
10.371.799
17.666.589
18.196.586
18.549.918
18.903.250

(SEDANG)

RINGAN
SEDANG
538
N-1-11-i
539
N-1-11-ii
540
N-1-11-iii
541
N-1-12-i
542
N-1-12-ii
543
N-1-12-iii
544
N-1-20-i
5.641.230
5.810.467
5.923.291
6.036.116
545
N-1-20-ii
11.184.553
11.520.090
11.743.781
11.967.472
546
N-1-20-iii
12.794.115
13.177.939
13.433.821
13.689.703
6.711.239
6.912.576
7.046.801
7.181.025
10.198.564
10.504.521
10.708.492
10.912.464
11.241.108
11.578.341
11.803.163
12.027.986
6.047.483
6.228.907
6.349.857
6.470.807
8.197.579
8.443.506
8.607.458
8.771.409
9.534.021
9.820.042
10.010.722
10.201.402
2.358.735
2.429.497
2.476.672
2.523.846
3.451.383
3.554.924
3.623.952
3.692.980
6.801.566
7.005.613
7.141.644
7.277.675


URIN BAWAH RINGAN
URIN BAWAH SEDANG
URIN BAWAH BERAT
RINGAN
SEDANG
BERAT
GINJAL RINGAN
GINJAL SEDANG
GINJAL BERAT
547
N-1-30-i
548
N-1-30-ii
549
N-1-30-iii
550
N-1-40-i
551
N-1-40-ii
552
N-1-40-iii
553
N-4-10-i
554
N-4-10-ii
555
N-4-10-iii
556
N-4-11-i
1.973.880
2.033.096
2.072.574
2.112.051
557
N-4-11-ii
3.335.809
3.435.883
3.502.599
3.569.315
558
N-4-11-iii
3.817.254
3.931.772
4.008.117
4.084.462
559
N-4-12-i
1.908.650
1.965.909
2.004.082
2.042.255
560
N-4-12-ii
2.682.556
2.763.032
2.816.683
2.870.334
561
N-4-12-iii
4.216.255
4.342.742
4.427.067
4.511.392
562
N-4-13-i
BATU URIN RINGAN
2.720.442
2.802.055
2.856.464
2.910.873
563
N-4-13-ii
BATU URIN SEDANG
3.279.830
3.378.225
3.443.822
3.509.418
564
N-4-13-iii
BATU URIN BERAT
8.077.322
8.319.642
8.481.188
8.642.734
- 470 No
Kode
INA-CBG
565
N-4-14-i
566
N-4-14-ii
567
N-4-14-iii
568
N-4-15-i
569
N-4-15-ii
570
N-4-15-iii
571
N-4-16-i
572
N-4-16-ii
573
N-4-16-iii
574
O-6-10-i
575
O-6-10-ii
576
O-6-10-iii
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
584
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.341.219
1.381.455
1.408.279
1.435.104
2.065.308
2.127.267
2.168.573
2.209.879
3.349.271
3.449.749
3.516.735
3.583.720
2.649.810
2.729.304
2.782.300
2.835.296
3.636.363
3.745.454
3.818.182
3.890.909
4.149.747
4.274.239
4.357.234
4.440.229
2.661.252
2.741.090
2.794.315
2.847.540
3.434.281
3.537.309
3.605.995
3.674.681
6.849.634
7.055.124
7.192.116
7.329.109
3.310.105
3.409.408
3.475.610
3.541.813
3.674.721
3.784.963
3.858.457
3.931.952
4.528.501
4.664.356
4.754.927
4.845.497
2.089.713
2.152.405
2.194.199
2.235.993
3.404.756
3.506.899
3.574.994
3.643.089
5.770.005
5.943.105
6.058.505
6.173.905
2.311.059
2.380.391
2.426.612
2.472.833
2.775.576
2.858.843
2.914.355
2.969.866
3.487.113
3.591.727
3.661.469
3.731.211
1.637.666
1.686.796
1.719.549
1.752.303
O-6-13-ii
1.913.196
1.970.592
2.008.856
2.047.120
585
O-6-13-iii
2.379.313
2.450.692
2.498.278
2.545.865
586
P-8-01-i
38.905.347
40.072.508
40.850.615
41.628.722
587
P-8-01-ii
48.139.282
49.583.460
50.546.246
51.509.031
588
P-8-01-iii
56.502.022
58.197.083
59.327.123
60.457.163
589
P-8-02-i
62.771.925
64.655.083
65.910.521
67.165.960
590
P-8-02-ii
72.005.859
74.166.035
75.606.152
77.046.269

(RINGAN)
(SEDANG)
(BERAT)
SALURAN URIN RINGAN
SALURAN URIN SEDANG
SALURAN URIN BERAT
RINGAN
SEDANG
BERAT
&KURET RINGAN
KURET SEDANG
KURET BERAT

- 471 No
Kode
INA-CBG
591
P-8-02-iii
592
P-8-03-i
593
P-8-03-ii
594
P-8-03-iii
595
P-8-04-i
596
P-8-04-ii
597
P-8-04-iii
598
P-8-05-i
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii
603
P-8-06-iii
604
P-8-07-i
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
614
P-8-11-ii
615
P-8-11-iii
616
P-8-12-i
617
P-8-12-ii
618
P-8-12-iii
Deskripsi (INA-CBG)
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
RINGAN
SEDANG
BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
82.271.842
84.739.998
86.385.435
88.030.871
2.581.332
2.658.772
2.710.399
2.762.025
3.844.799
3.960.143
4.037.039
4.113.935
6.987.448
7.197.072
7.336.821
7.476.570
31.008.792
31.939.055
32.559.231
33.179.407
40.242.726
41.450.008
42.254.862
43.059.717
57.697.940
59.428.878
60.582.836
61.736.795
16.861.575
17.367.423
17.704.654
18.041.886
23.899.010
24.615.980
25.093.961
25.571.941
35.211.983
36.268.343
36.972.582
37.676.822
2.361.240
2.432.078
2.479.303
2.526.527
6.195.197
6.381.053
6.504.957
6.628.861
11.357.862
11.698.598
11.925.755
12.152.912
4.480.954
4.615.383
4.705.002
4.794.621
11.065.125
11.397.079
11.618.381
11.839.684
14.878.781
15.325.145
15.622.720
15.920.296
3.522.692
3.628.372
3.698.826
3.769.280
5.000.956
5.150.985
5.251.004
5.351.023
6.385.666
6.577.236
6.704.950
6.832.663
2.185.474
2.251.038
2.294.747
2.338.457
3.165.977
3.260.956
3.324.276
3.387.595
6.215.745
6.402.218
6.526.533
6.650.848
2.155.335
2.219.995
2.263.102
2.306.208
13.104.301
13.497.430
13.759.516
14.021.602
13.378.838
13.780.203
14.047.780
14.315.357
2.903.873
2.990.989
3.049.066
3.107.144
4.515.018
4.650.468
4.740.769
4.831.069
5.326.766
5.486.569
5.593.104
5.699.640
- 472 No
Kode
INA-CBG
619
P-8-13-i
620
P-8-13-ii
621
P-8-13-iii
622
P-8-14-i
623
P-8-14-ii
624
P-8-14-iii
625
P-8-15-i
626
P-8-15-ii
627
P-8-15-iii
628
P-8-16-i
629
P-8-16-ii
630
P-8-16-iii
631
P-8-17-i
632
P-8-17-ii
633
P-8-17-iii
634
S-4-10-i
635
S-4-10-ii
636
S-4-10-iii
637
S-4-11-i
638
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.500.878
1.545.904
1.575.922
1.605.939
2.777.363
2.860.684
2.916.231
2.971.778
4.153.843
4.278.458
4.361.535
4.444.612
2.742.260
2.824.528
2.879.373
2.934.218
5.598.919
5.766.886
5.878.865
5.990.843
6.141.993
6.326.253
6.449.093
6.571.933
2.062.265
2.124.133
2.165.378
2.206.624
4.121.926
4.245.583
4.328.022
4.410.460
4.841.840
4.987.095
5.083.932
5.180.769
1.866.837
1.922.842
1.960.179
1.997.516
2.648.188
2.727.634
2.780.598
2.833.562
3.437.479
3.540.603
3.609.353
3.678.102
1.229.872
1.266.768
1.291.365
1.315.963
4.092.648
4.215.427
4.297.280
4.379.133
8.260.749
8.508.571
8.673.786
8.839.001
1.532.986
1.578.975
1.609.635
1.640.295
1.916.232
1.973.719
2.012.044
2.050.369
2.490.773
2.565.496
2.615.312
2.665.127
958.116
986.860
1.006.022
1.025.184
S-4-11-ii
1.532.986
1.578.975
1.609.635
1.640.295
639
S-4-11-iii
2.359.227
2.430.004
2.477.189
2.524.373
640
S-4-12-i
1.181.670
1.217.120
1.240.754
1.264.387
641
S-4-12-ii
1.616.220
1.664.707
1.697.032
1.729.356
642
S-4-12-iii
3.091.987
3.184.747
3.246.587
3.308.426
643
S-4-13-i
1.836.505
1.891.601
1.928.331
1.965.061
644
S-4-13-ii
3.025.345
3.116.105
3.176.612
3.237.119
645
S-4-13-iii
5.861.493
6.037.338
6.154.568
6.271.798
646
S-4-14-i
943.424
971.726
990.595
1.009.463
647
S-4-14-ii
2.004.148
2.064.273
2.104.356
2.144.439
648
S-4-14-iii
3.800.580
3.914.597
3.990.609
4.066.620
649
S-4-15-i
713.520
734.926
749.196
763.466
650
S-4-15-ii
1.346.655
1.387.055
1.413.988
1.440.921

MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
ASPIRASI RINGAN
ASPIRASI SEDANG
ASPIRASI BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT

PASIEN RINGAN
PASIEN SEDANG
PASIEN BERAT
- 473 No
Kode
INA-CBG
651
S-4-15-iii
652
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

1.744.232
1.796.559
1.831.443
1.866.328
S-4-16-i
LUKA BAKAR RINGAN
2.929.171
3.017.046
3.075.630
3.134.213
653
S-4-16-ii
LUKA BAKAR SEDANG
5.096.434
5.249.327
5.351.256
5.453.184
654
S-4-16-iii
LUKA BAKAR BERAT
9.100.474
9.373.488
9.555.498
9.737.507
655
S-4-17-i
1.924.144
1.981.869
2.020.352
2.058.834
656
S-4-17-ii
2.240.864
2.308.090
2.352.907
2.397.725
657
S-4-17-iii
3.461.595
3.565.442
3.634.674
3.703.906
658
T-1-10-i
2.500.041
2.575.042
2.625.043
2.675.044
659
T-1-10-ii
3.357.385
3.458.107
3.525.255
3.592.402
660
T-1-10-iii
6.108.178
6.291.423
6.413.587
6.535.751
661
T-4-10-i
821.201
845.837
862.261
878.685
662
T-4-10-ii
1.565.027
1.611.978
1.643.278
1.674.579
663
T-4-10-iii
2.275.124
2.343.378
2.388.881
2.434.383
664
T-4-11-i
1.081.497
1.113.942
1.135.572
1.157.202
665
T-4-11-ii
1.701.969
1.753.028
1.787.067
1.821.106
666
T-4-11-iii
2.741.370
2.823.611
2.878.439
2.933.266
667
T-4-12-i
1.779.878
1.833.274
1.868.872
1.904.469
668
T-4-12-ii
2.652.064
2.731.626
2.784.668
2.837.709
669
T-4-12-iii
4.084.242
4.206.769
4.288.454
4.370.139
670
U-1-10-i
1.442.132
1.485.396
1.514.239
1.543.081
671
U-1-10-ii
2.942.759
3.031.042
3.089.897
3.148.752
672
U-1-10-iii
12.707.429
13.088.652
13.342.801
13.596.949
6.195.197
6.381.053
6.504.957
6.628.861
8.260.263
8.508.071
8.673.276
8.838.482
18.667.300
19.227.319
19.600.665
19.974.011

DOKTER RINGAN
DOKTER SEDANG
DOKTER BERAT

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
673
U-1-11-i
674
U-1-11-ii
675
U-1-11-iii
676
U-1-12-i
5.092.493
5.245.268
5.347.118
5.448.967
677
U-1-12-ii
9.292.796
9.571.580
9.757.436
9.943.292
678
U-1-12-iii
12.066.872
12.428.878
12.670.215
12.911.553
679
U-1-13-i
4.130.132
4.254.036
4.336.638
4.419.241
680
U-1-13-ii
5.162.664
5.317.544
5.420.798
5.524.051
681
U-1-13-iii
8.985.619
9.255.187
9.434.900
9.614.612
- 474 No
Kode
INA-CBG
682
U-1-14-i
683
U-1-14-ii
684
U-1-14-iii
685
U-1-15-i
686
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.065.322
3.157.282
3.218.588
3.279.895
3.761.767
3.874.620
3.949.855
4.025.091
4.457.800
4.591.534
4.680.690
4.769.846
1.800.381
1.854.392
1.890.400
1.926.407
U-1-15-ii
2.558.215
2.634.962
2.686.126
2.737.290
687
U-1-15-iii
5.041.066
5.192.298
5.293.119
5.393.941
688
U-1-20-i
4.656.801
4.796.505
4.889.641
4.982.777
689
U-1-20-ii
7.320.324
7.539.934
7.686.340
7.832.747
690
U-1-20-iii
15.202.952
15.659.040
15.963.099
16.267.158
691
U-1-30-i
3.994.723
4.114.565
4.194.459
4.274.354
692
U-1-30-ii
5.392.876
5.554.662
5.662.520
5.770.377
693
U-1-30-iii
8.260.263
8.508.071
8.673.276
8.838.482
694
U-4-10-i
3.718.420
3.829.972
3.904.341
3.978.709
695
U-4-10-ii
9.321.298
9.600.937
9.787.362
9.973.788
696
U-4-10-iii
13.597.743
14.005.676
14.277.630
14.549.585
697
U-4-11-i
1.725.638
1.777.407
1.811.920
1.846.433
698
U-4-11-ii
2.299.479
2.368.463
2.414.453
2.460.442
699
U-4-11-iii
4.277.654
4.405.984
4.491.537
4.577.090
700
U-4-12-i
1.532.986
1.578.975
1.609.635
1.640.295
701
U-4-12-ii
2.403.844
2.475.959
2.524.036
2.572.113
702
U-4-12-iii
3.822.002
3.936.662
4.013.102
4.089.542
703
U-4-13-i
1.532.986
1.578.975
1.609.635
1.640.295
704
U-4-13-ii
1.750.866
1.803.392
1.838.409
1.873.427
705
U-4-13-iii
2.674.037
2.754.258
2.807.739
2.861.220
706
U-4-14-i
1.916.232
1.973.719
2.012.044
2.050.369
707
U-4-14-ii
2.299.479
2.368.463
2.414.453
2.460.442
708
U-4-14-iii
3.876.444
3.992.737
4.070.266
4.147.795
1.651.240
1.700.778
1.733.802
1.766.827
2.174.616
2.239.855
2.283.347
2.326.840
2.949.352
3.037.832
3.096.819
3.155.806
5.093.698
5.246.509
5.348.383
5.450.257
5.781.795
5.955.249
6.070.885
6.186.521
9.809.062
10.103.334
10.299.516
10.495.697
709
U-4-15-i
710
U-4-15-ii
711
U-4-15-iii
712
V-1-10-i
713
V-1-10-ii
714
V-1-10-iii



DAN TELINGA RINGAN
DAN TELINGA SEDANG
DAN TELINGA BERAT


KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT
- 475 No
Kode
INA-CBG
715
V-1-11-i
716
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.162.664
5.317.544
5.420.798
5.524.051
V-1-11-ii
5.761.620
5.934.469
6.049.701
6.164.934
717
V-1-11-iii
8.532.077
8.788.040
8.958.681
9.129.323
718
V-1-12-i
3.750.487
3.863.002
3.938.011
4.013.021
719
V-1-12-ii
11.448.951
11.792.420
12.021.399
12.250.378
720
V-1-12-iii
12.875.847
13.262.122
13.519.639
13.777.156
721
V-1-13-i
5.684.522
5.855.058
5.968.749
6.082.439
722
V-1-13-ii
10.802.224
11.126.291
11.342.335
11.558.380
723
V-1-13-iii
12.390.395
12.762.107
13.009.914
13.257.722
724
V-1-14-i
6.852.758
7.058.341
7.195.396
7.332.451
725
V-1-14-ii
9.966.749
10.265.752
10.465.087
10.664.422
726
V-1-14-iii
13.485.400
13.889.962
14.159.670
14.429.378
727
V-1-15-i
3.097.599
3.190.527
3.252.479
3.314.431
728
V-1-15-ii
4.834.006
4.979.026
5.075.706
5.172.387
729
V-1-15-iii
8.042.762
8.284.045
8.444.900
8.605.756
5.202.233
5.358.300
5.462.344
5.566.389
6.719.305
6.920.884
7.055.270
7.189.656
12.841.771
13.227.024
13.483.859
13.740.695
2.645.530
2.724.896
2.777.807
2.830.717
3.865.542
3.981.508
4.058.819
4.136.130
6.377.889
6.569.225
6.696.783
6.824.341
7.779.154
8.012.529
8.168.112
8.323.695
9.369.622
9.650.711
9.838.103
10.025.496
16.965.436
17.474.400
17.813.708
18.153.017

NON KOMPLEK (BERAT)

RINGAN
SEDANG
BERAT
730
V-4-10-i
731
V-4-10-ii
732
V-4-10-iii
733
V-4-11-i
734
V-4-11-ii
735
V-4-11-iii
736
W-1-01-i
737
W-1-01-ii
738
W-1-01-iii
739
W-1-10-i
2.065.066
2.127.018
2.168.319
2.209.620
740
W-1-10-ii
4.043.017
4.164.307
4.245.167
4.326.028
741
W-1-10-iii
6.613.092
6.811.485
6.943.747
7.076.009
742
W-1-11-i
2.250.257
2.317.765
2.362.770
2.407.775
743
W-1-11-ii
4.130.132
4.254.036
4.336.638
4.419.241
744
W-1-11-iii
6.195.197
6.381.053
6.504.957
6.628.861
745
W-1-12-i
2.044.697
2.106.038
2.146.932
2.187.826
746
W-1-12-ii
2.324.781
2.394.525
2.441.021
2.487.516

SERVIK RINGAN
SERVIK SEDANG
SERVIK BERAT
- 476 No
Kode
INA-CBG
747
W-1-12-iii
748
W-1-13-i
749
W-1-13-ii
750
W-1-13-iii
751
W-1-20-i
752
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.571.157
3.678.292
3.749.715
3.821.138
1.827.500
1.882.325
1.918.875
1.955.425
1.984.139
2.043.663
2.083.345
2.123.028
2.665.064
2.745.016
2.798.317
2.851.619
6.631.065
6.829.997
6.962.618
7.095.240
W-1-20-ii
8.260.263
8.508.071
8.673.276
8.838.482
753
W-1-20-iii
9.292.796
9.571.580
9.757.436
9.943.292
754
W-1-30-i
3.619.897
3.728.494
3.800.891
3.873.289
755
W-1-30-ii
5.162.664
5.317.544
5.420.798
5.524.051
756
W-1-30-iii
15.354.280
15.814.909
16.121.994
16.429.080
757
W-4-10-i
2.699.536
2.780.522
2.834.513
2.888.503
758
W-4-10-ii
3.648.725
3.758.187
3.831.162
3.904.136
759
W-4-10-iii
6.558.995
6.755.765
6.886.945
7.018.125
760
W-4-11-i
1.916.232
1.973.719
2.012.044
2.050.369
761
W-4-11-ii
3.215.802
3.312.276
3.376.592
3.440.908
762
W-4-11-iii
3.882.540
3.999.016
4.076.667
4.154.318
763
W-4-12-i
1.532.986
1.578.975
1.609.635
1.640.295
764
W-4-12-ii
2.620.091
2.698.694
2.751.096
2.803.498
765
W-4-12-iii
3.161.024
3.255.855
3.319.075
3.382.296
766
W-4-13-i
ABORTUS RINGAN
840.708
865.929
882.743
899.557
767
W-4-13-ii
ABORTUS SEDANG
1.149.739
1.184.232
1.207.226
1.230.221
768
W-4-13-iii
ABORTUS BERAT
1.532.986
1.578.975
1.609.635
1.640.295
769
W-4-14-i
1.149.739
1.184.232
1.207.226
1.230.221
770
W-4-14-ii
1.532.986
1.578.975
1.609.635
1.640.295
771
W-4-14-iii
1.860.721
1.916.542
1.953.757
1.990.971
772
W-4-15-i
1.149.739
1.184.232
1.207.226
1.230.221
773
W-4-15-ii
1.235.684
1.272.754
1.297.468
1.322.182
774
W-4-15-iii
1.563.359
1.610.260
1.641.527
1.672.794
775
W-4-16-i
1.293.846
1.332.662
1.358.539
1.384.416
776
W-4-16-ii
2.049.852
2.111.347
2.152.344
2.193.341
777
W-4-16-iii
2.612.492
2.690.866
2.743.116
2.795.366
778
W-4-17-i
1.149.739
1.184.232
1.207.226
1.230.221
779
W-4-17-ii
1.532.986
1.578.975
1.609.635
1.640.295

ENDOSKOP RINGAN
ENDOSKOP SEDANG
ENDOSKOP BERAT

RINGAN
SEDANG
BERAT

- 477 No
Kode
INA-CBG
780
W-4-17-iii
781
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.900.104
2.987.108
3.045.110
3.103.112
Z-4-10-i
REHABILITASI RINGAN
3.344.180
3.444.506
3.511.389
3.578.273
782
Z-4-10-ii
REHABILITASI SEDANG
4.438.917
4.572.084
4.660.862
4.749.641
783
Z-4-10-iii
REHABILITASI BERAT
6.305.904
6.495.081
6.621.200
6.747.318
784
Z-4-11-i
3.088.448
3.181.101
3.242.870
3.304.639
785
Z-4-11-ii
3.717.809
3.829.343
3.903.699
3.978.055
786
Z-4-11-iii
5.812.283
5.986.651
6.102.897
6.219.142
787
Z-4-12-i
1.194.537
1.230.373
1.254.264
1.278.154
788
Z-4-12-ii
3.150.978
3.245.507
3.308.527
3.371.546
789
Z-4-12-iii
4.004.394
4.124.526
4.204.614
4.284.701

b. RawatJalan
No
Kode
INA-CBG
B-2-10-0
B-2-11-0
- 478 -
Deskripsi (INA-CBG)
LAPAROSKOPI
PANKREAS
LAPAROSKOPI
EMPEDU
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
775.006
798.256
813.756
829.256
1.005.304
1.035.463
1.055.569
1.075.675
1.869.494
1.925.579
1.962.969
2.000.359
1.544.956
1.591.304
1.622.204
1.653.103
1.290.677
1.329.398
1.355.211
1.381.025
452.517
466.093
475.143
484.193
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
1.009.054
1.039.326
1.059.507
1.079.688
B-3-12-0

207.327
213.547
217.694
221.840
C-3-10-0
565.560
582.527
593.838
605.149
10
C-3-11-0

KANDUNG KEMIH
894.454
921.288
939.177
957.066
11
C-3-12-0
202.771
208.854
212.909
216.965
12
C-3-13-0
196.904
202.812
206.750
210.688
13
C-3-14-0
1.676.251
1.726.538
1.760.063
1.793.588
14
C-3-15-0
1.536.351
1.582.441
1.613.168
1.643.895
15
C-3-16-0
348.407
358.860
365.828
372.796
16
C-3-17-0

LEHER
231.123
238.057
242.679
247.302
17
C-3-18-0
102.470
105.544
107.594
109.643
18
C-3-19-0

MYELOMA ATAU TESTIS
144.913
149.261
152.159
155.057
19
C-3-20-0
2.885.957
2.972.536
3.030.255
3.087.974
20
C-3-21-0
165.372
170.333
173.641
176.948
21
C-3-22-0
726.072
747.854
762.376
776.897
22
C-3-23-0
117.608
121.136
123.488
125.840
23
D-2-10-0

TULANG
996.390
1.026.282
1.046.209
1.066.137
24
D-2-11-0
PROSEDUR LIMPA
1.247.650
1.285.080
1.310.033
1.334.986
25
D-2-21-0
1.046.425
1.077.818
1.098.747
1.119.675
26
D-2-22-0
229.659
236.549
241.142
245.735
27
D-3-10-0
166.348
171.338
174.665
177.992
28
D-3-11-0
431.886
444.843
453.481
462.118
29
E-2-10-0
256.192
263.877
269.001
274.125
30
E-2-21-0
185.730
191.302
195.017
198.731
31
E-2-22-0
185.730
191.302
195.017
198.731

OVARIUM
GASTROINTESTINAL
GINJAL ATAU PROSTAT

TYMUS
TYMUS
TULANG
PEMBENTUK DARAH
DAN PARATIROID
THYROGLOSSAL
- 479 No
Kode
INA-CBG
32
E-3-10-0
33
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

ENDOKRIN
215.992
222.472
226.792
231.112
F-3-10-0
TERAPI SHOCK
311.084
320.416
326.638
332.860
34
F-5-10-0
381.178
392.614
400.237
407.861
35
F-5-11-0
TERAPI KELOMPOK
251.352
258.893
263.920
268.947
36
F-5-12-0
321.648
331.297
337.730
344.163
37
F-5-13-0
272.414
280.587
286.035
291.483
38
F-5-14-0
182.753
188.236
191.891
195.546
39
F-5-15-0
171.446
176.590
180.019
183.447
40
F-5-16-0
178.578
183.935
187.507
191.078
41
G-2-10-0
145.648
150.017
152.930
155.843
42
G-2-11-0
1.262.536
1.300.412
1.325.663
1.350.914
43
G-2-12-0

EKSTRAKRANIAL
1.829.726
1.884.618
1.921.212
1.957.807
44
G-2-13-0
448.873
462.339
471.316
480.294
45
G-2-21-0
818.668
843.228
859.601
875.975
46
G-2-22-0
743.011
765.301
780.161
795.022
47
G-2-31-0
1.226.033
1.262.814
1.287.334
1.311.855
48
G-2-32-0
628.463
647.317
659.886
672.456
49
G-3-10-0
249.441
256.924
261.913
266.902
50
G-3-11-0
332.208
342.174
348.818
355.462
51
G-3-12-0
544.328
560.658
571.544
582.431
52
G-3-13-0
544.390
560.722
571.610
582.497
53
H-2-21-0
714.431
735.864
750.153
764.441
54
H-2-22-0
185.730
191.302
195.017
198.731
55
H-2-23-0
185.730
191.302
195.017
198.731
56
H-2-31-0
1.183.396
1.218.898
1.242.565
1.266.233
57
H-2-32-0
123.164
126.859
129.322
131.785
58
H-2-33-0
185.730
191.302
195.017
198.731
59
H-2-34-0
530.900
546.827
557.445
568.063
60
H-2-35-0
174.944
180.192
183.691
187.190
61
H-2-36-0
944.305
972.634
991.520
1.010.406
62
H-2-37-0

1.005.254
1.035.412
1.055.517
1.075.622
63
H-3-10-0
349.755
360.248
367.243
374.238
64
H-3-11-0
183.932
189.450
193.129
196.808

AKUT
MENTAL
PROSEDUR KRANIOTOMI

MATA
MATA
MATA
MATA
MATA
- 480 No
Kode
INA-CBG
65
H-3-12-0
66
H-3-13-0
67
I-2-11-0
68
I-2-12-0
69
I-2-13-0
70
I-2-14-0
71
I-2-15-0
Deskripsi (INA-CBG)
MATA
TORASIK
ABDOMEN
PENGGANTIAN ALAT
DARAH VENA
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
192.035
197.796
201.636
205.477
186.454
192.048
195.777
199.506
2.150.214
2.214.720
2.257.725
2.300.729
1.511.835
1.557.190
1.587.427
1.617.663
1.921.451
1.979.095
2.017.524
2.055.953
3.400.560
3.502.576
3.570.588
3.638.599
204.503
210.638
214.728
218.818
2.147.884
2.212.320
2.255.278
2.298.235
708.096
729.338
743.500
757.662
72
I-2-16-0
73
I-2-17-0
74
I-2-21-0
1.657.861
1.707.597
1.740.754
1.773.911
75
I-2-22-0
1.561.166
1.608.001
1.639.225
1.670.448
76
I-2-23-0
319.488
329.073
335.462
341.852
77
I-2-31-0
2.484.766
2.559.309
2.609.004
2.658.700
78
I-2-32-0
3.249.197
3.346.672
3.411.656
3.476.640
79
I-2-41-0
2.178.626
2.243.985
2.287.558
2.331.130
80
I-2-42-0

LAIN
2.533.013
2.609.004
2.659.664
2.710.324
81
I-3-10-0
PROSEDUR RESUSITASI
321.544
331.190
337.621
344.052
82
I-3-11-0
169.710
174.801
178.195
181.590
83
I-3-12-0
986.290
1.015.879
1.035.605
1.055.331
84
I-3-13-0
323.936
333.654
340.133
346.611
85
I-3-14-0
207.632
213.861
218.013
222.166
183.932
189.450
193.129
196.808
1.138.791
1.172.955
1.195.730
1.218.506
183.573
189.080
192.752
196.423
925.093
952.845
971.347
989.849
1.199.928
1.235.926
1.259.924
1.283.923

PACU JANTUNG

KARDIOVASKULAR
PERNAFASAN
PENDEK
86
I-3-15-0
87
J-2-10-0
88
J-2-21-0
89
J-2-22-0
90
J-2-31-0
PROSEDUR
91
J-2-32-0
892.945
919.734
937.593
955.452
92
J-3-10-0
185.730
191.302
195.017
198.731
93
J-3-11-0

PADA DADA
524.840
540.586
551.082
561.579
94
J-3-12-0
202.771
208.854
212.909
216.965
95
J-3-13-0
298.428
307.381
313.350
319.318
96
J-3-14-0
316.814
326.318
332.655
338.991
- 481 No
Kode
INA-CBG
97
J-3-15-0
98
J-3-16-0
99
J-3-17-0
100
K-2-10-0
101
K-2-11-0
102
K-2-12-0

103
K-2-13-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
277.821
286.155
291.712
297.268
316.814
326.318
332.655
338.991
185.730
191.302
195.017
198.731
534.595
550.633
561.325
572.017
1.141.578
1.175.826
1.198.657
1.221.489
876.309
902.598
920.124
937.650
1.426.240
1.469.027
1.497.552
1.526.077
185.730
191.302
195.017
198.731
185.730
191.302
195.017
198.731
2.387.075
2.458.687
2.506.429
2.554.170
802.652
826.732
842.785
858.838
185.730
191.302
195.017
198.731

PERNAFASAN
KECIL

FEMORALIS
USUS BESAR
ATAS
ATAS
104
K-2-14-0
105
K-2-21-0
106
K-2-22-0
107
K-2-31-0
108
K-2-32-0
109
K-2-41-0
884.138
910.662
928.345
946.027
110
K-2-42-0

252.609
260.187
265.240
270.292
111
K-2-51-0
585.883
603.460
615.177
626.895
112
K-2-52-0
319.488
329.073
335.462
341.852
113
K-2-53-0
185.730
191.302
195.017
198.731
114
K-3-10-0

GASTROINTESTINAL
353.432
364.035
371.104
378.172
115
K-3-11-0
212.482
218.856
223.106
227.355
116
K-3-12-0
215.483
221.948
226.257
230.567
117
K-3-13-0
185.730
191.302
195.017
198.731
497.761
512.694
522.649
532.604
240.376
247.587
252.394
257.202
318.513
328.068
334.439
340.809
1.095.060
1.127.911
1.149.813
1.171.714
701.925
722.983
737.022
751.060
316.814
326.318
332.655
338.991
319.488
329.073
335.462
341.852

GASTROINTESTINAL
LUKA BAKAR
LUKA BAKAR
TANPA LUKA BAKAR
LUKA BAKAR
118
K-3-14-0
119
K-3-15-0
120
K-3-16-0
121
L-2-21-0
122
L-2-22-0
123
L-2-31-0
124
L-2-32-0
125
L-2-41-0
956.669
985.369
1.004.502
1.023.636
126
L-2-42-0

214.565
221.002
225.294
229.585
127
L-2-51-0
1.432.283
1.475.252
1.503.897
1.532.543
L-2-52-0

1.095.744
1.128.616
1.150.531
1.172.446
128
- 482 No
Kode
INA-CBG
129
L-2-53-0
130
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

185.730
191.302
195.017
198.731
L-3-10-0
252.609
260.187
265.240
270.292
131
L-3-11-0
245.301
252.660
257.566
262.472
132
L-3-12-0
186.820
192.425
196.161
199.897
133
M-2-10-0
1.465.330
1.509.290
1.538.597
1.567.903
134
M-2-21-0
1.312.305
1.351.674
1.377.920
1.404.166
135
M-2-22-0
319.488
329.073
335.462
341.852
136
M-2-31-0
PROSEDUR BUNION
797.093
821.006
836.948
852.890
137
M-2-32-0
252.609
260.187
265.240
270.292
138
M-2-41-0

TULANG
252.609
260.187
265.240
270.292
139
M-2-42-0
87.056
89.668
91.409
93.150
140
M-2-51-0
185.730
191.302
195.017
198.731
141
M-2-52-0
185.730
191.302
195.017
198.731
142
M-2-61-0
PROSEDUR ARTROSKOPI
910.361
937.672
955.879
974.086
143
M-2-62-0
185.730
191.302
195.017
198.731
915.285
942.744
961.050
979.355
1.248.260
1.285.708
1.310.673
1.335.639
185.730
191.302
195.017
198.731
921.544
949.191
967.621
986.052
889.329
916.009
933.796
951.583
1.326.180
1.365.965
1.392.489
1.419.012
963.384
992.286
1.011.554
1.030.821
185.730
191.302
195.017
198.731
185.730
191.302
195.017
198.731
530.110
546.013
556.615
567.217
293.914
302.731
308.609
314.487
664.663
684.603
697.896
711.189

DAN WAJAH
PAHA
PAHA

TULANG
WAJAH
WAJAH
BAWAH
BAWAH
BAHU
BAHU
PERGELANGAN TANGAN
PERGELANGAN TANGAN
144
M-2-63-0
145
M-2-64-0
146
M-2-65-0
147
M-2-71-0
148
M-2-72-0
149
M-2-81-0
150
M-2-82-0
151
M-2-83-0
152
M-2-84-0
153
M-3-10-0
154
M-3-11-0
155
M-3-12-0
156
M-3-13-0
216.698
223.199
227.533
231.867
157
M-3-14-0

TERTUTUP
370.374
381.485
388.892
396.300
158
M-3-15-0
163.172
168.067
171.331
174.594
159
M-3-16-0

185.730
191.302
195.017
198.731
160
M-3-17-0
202.771
208.854
212.909
216.965
161
N-2-11-0
2.453.678
2.527.288
2.576.362
2.625.435

MUSKULOSKELETAL
SKELETAL
- 483 No
Kode
INA-CBG
162
N-2-12-0
163
N-2-21-0
164
N-2-22-0
165
N-2-23-0
166
N-2-24-0
167
N-2-31-0
168
N-2-32-0
169
N-2-41-0
170
N-2-42-0
171
N-3-10-0
172
N-3-11-0
173
N-3-12-0
174
N-3-13-0
175
N-3-14-0
176
N-3-15-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.419.428
1.462.011
1.490.400
1.518.788
1.411.946
1.454.305
1.482.544
1.510.783
319.488
329.073
335.462
341.852

URETER
319.488
329.073
335.462
341.852
1.032.478
1.063.452
1.084.102
1.104.751
869.179
895.254
912.638
930.022
319.488
329.073
335.462
341.852
319.488
329.073
335.462
341.852
540.315
556.525
567.331
578.138
319.488
329.073
335.462
341.852
370.172
381.278
388.681
396.085
286.049
294.630
300.351
306.072
319.488
329.073
335.462
341.852
274.902
283.149
288.647
294.145
704.918
726.066
740.164
754.262
117.691
121.222
123.575
125.929
648.155
667.600
680.563
693.526
236.015
243.096
247.816
252.536
131.167
135.102
137.725
140.348
174.944
180.192
183.691
187.190


DAN URETHRA
DAN URETHRA
TRANSURETHRA
TRANSURETHRA
SALURAN KEMIH
KEMIH
KEMIH
PROSEDUR DIALISIS
CAESAR
VAGINAL/JALAN LAHIR
177
O-7-10-0
178
O-7-11-0
179
O-7-12-0
180
O-7-13-0
181
P-9-10-0
182
P-9-11-0
174.944
180.192
183.691
187.190
183
P-9-12-0
174.944
180.192
183.691
187.190
184
P-9-13-0
174.944
180.192
183.691
187.190
185
P-9-14-0
174.944
180.192
183.691
187.190
186
P-9-15-0
111.513
114.858
117.088
119.319
187
P-9-16-0
174.944
180.192
183.691
187.190
188
P-9-17-0
174.191
179.417
182.901
186.385
189
Q-5-10-0
235.410
242.472
247.180
251.888
190
Q-5-11-0
176.433
181.726
185.255
188.783
191
Q-5-12-0
GIGI
155.503
160.169
163.279
166.389
192
Q-5-13-0
MEDICAL CHECK-UP
118.176
121.721
124.085
126.448
193
Q-5-14-0
130.032
133.933
136.534
139.134

ASPIRASI
- 484 No
Kode
INA-CBG
194
Q-5-15-0
195
Q-5-16-0
VAKSINASI
196
Q-5-17-0
PASANG INFUS
197
Q-5-18-0
198
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
89.423
92.106
93.894
95.683
101.069
104.101
106.122
108.143
87.422
90.044
91.793
93.541
164.555
169.492
172.783
176.074
Q-5-19-0
183.963
189.481
193.161
196.840
199
Q-5-20-0
ABORSI MENGANCAM
123.304
127.003
129.469
131.935
200
Q-5-21-0
ABORSI
121.625
125.273
127.706
130.138
201
Q-5-22-0
130.032
133.933
136.534
139.134
202
Q-5-23-0
159.194
163.969
167.153
170.337
203
Q-5-24-0
108.727
111.989
114.163
116.338
204
Q-5-25-0
169.557
174.644
178.035
181.426
205
Q-5-26-0
BRONKIAL AKUT
239.997
247.197
251.997
256.797
206
Q-5-27-0
170.793
175.917
179.333
182.749
207
Q-5-28-0
138.594
142.752
145.524
148.296
208
Q-5-29-0

JANTUNG LAIN-LAIN
392.384
404.155
412.003
419.850
209
Q-5-30-0
454.730
468.372
477.467
486.561
210
Q-5-31-0
FRAKTUR
162.230
167.096
170.341
173.586
211
Q-5-32-0
SALURAN KEMIH AKUT
187.898
193.535
197.293
201.051
212
Q-5-33-0
HEMATOLOGI AKUT
196.729
202.631
206.565
210.500
213
Q-5-34-0
INFEKSI VIRUS HIV
279.467
287.851
293.441
299.030
214
Q-5-35-0
INFEKSI AKUT
316.908
326.416
332.754
339.092
215
Q-5-36-0
369.060
380.132
387.513
394.894
216
Q-5-37-0

SHOCK
188.240
193.887
197.652
201.416
217
Q-5-38-0
PARU AKUT
251.024
258.554
263.575
268.595
218
Q-5-39-0
160.637
165.456
168.668
171.881
219
Q-5-40-0
157.610
162.339
165.491
168.643
220
Q-5-41-0
218.189
224.735
229.098
233.462
221
Q-5-42-0
171.069
176.201
179.622
183.044
222
Q-5-43-0
246.349
253.739
258.666
263.593
223
Q-5-44-0
201.055
207.087
211.108
215.129
224
T-2-10-0

TERAPI DETOKSIKASI
1.858.092
1.913.835
1.950.997
1.988.158
225
U-2-10-0
1.348.022
1.388.463
1.415.423
1.442.384
226
U-2-11-0

LEHER
1.602.274
1.650.343
1.682.388
1.714.434
227
U-2-12-0
176.292
181.581
185.107
188.632
- 485 No
Kode
INA-CBG
228
U-2-13-0
229
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
231.123
238.057
242.679
247.302
U-2-14-0
429.322
442.202
450.788
459.375
230
U-2-15-0
243.931
251.249
256.128
261.007
231
U-2-21-0
284.142
292.666
298.349
304.032
232
U-2-22-0
548.985
565.455
576.434
587.414
233
U-2-23-0
719.348
740.928
755.315
769.702
234
U-2-24-0
606.254
624.442
636.567
648.692
235
U-2-25-0
231.123
238.057
242.679
247.302
236
U-2-31-0
185.730
191.302
195.017
198.731
237
U-2-32-0
231.123
238.057
242.679
247.302
238
U-3-10-0
220.966
227.595
232.014
236.434
239
U-3-11-0
234.597
241.635
246.327
251.019
240
U-3-12-0
103.738
106.851
108.925
111.000
241
U-3-13-0
228.025
234.866
239.427
243.987
242
U-3-14-0
209.508
215.793
219.984
224.174
243
U-3-15-0
182.710
188.191
191.845
195.499
244
U-3-16-0
PROSEDUR PADA GIGI
206.063
212.245
216.367
220.488
245
V-2-10-0

PROSTAT
2.010.387
2.070.699
2.110.907
2.151.114
246
V-2-11-0
PROSEDUR PADA PENIS
226.721
233.522
238.057
242.591
247
V-2-12-0
723.497
745.202
759.672
774.142
248
V-2-13-0
319.488
329.073
335.462
341.852
249
V-2-14-0
319.488
329.073
335.462
341.852
250
V-2-15-0
SIRKUMSISI/SUNAT
174.944
180.192
183.691
187.190
251
V-3-10-0
364.857
375.802
383.100
390.397
771.861
795.017
810.454
825.891
445.616
458.984
467.897
476.809
163.172
168.067
171.331
174.594
417.007
429.518
437.858
446.198
771.861
795.017
810.454
825.891
123.793
127.507
129.982
132.458
1.551.647
1.598.196
1.629.229
1.660.262
252
V-3-11-0
253
V-3-12-0
254
W-2-10-0
255
W-2-11-0
256
W-2-12-0
257
W-2-13-0
258
W-2-21-0

(RHINOPLASTY)

TENGGOROKAN
RONGGA HIDUNG
TENGGOROKAN

SKROTUM
SKROTUM
TRANSURETHRAL

PROSEDUR ABORSI
RAHIM & LEHER RAHIM
TERHALANG/TERGANGGU
TERHALANG/TERGANGGU
PANGGUL TERBUKA
- 486 No
Kode
INA-CBG
259
W-2-22-0
260
W-2-23-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

PANGGUL TERBUKA
163.172
168.067
171.331
174.594
544.514
560.849
571.739
582.630
1.787.473
1.841.097
1.876.846
1.912.596
1.253.636
1.291.245
1.316.317
1.341.390

JALAN LAHIR
261
W-2-31-0
262
W-2-32-0
263
W-2-33-0
532.812
548.796
559.452
570.109
264
W-2-34-0
181.219
186.655
190.280
193.904
265
W-3-10-0
440.431
453.644
462.453
471.262
266
W-3-11-0
352.068
362.630
369.672
376.713
267
W-3-12-0
163.172
168.067
171.331
174.594
268
Z-3-10-0
1.847.327
1.902.747
1.939.693
1.976.640
269
Z-3-11-0

EMPEDU
1.411.946
1.454.305
1.482.544
1.510.783
270
Z-3-12-0
243.415
250.717
255.586
260.454
271
Z-3-13-0

LAIN-LAIN
1.438.678
1.481.838
1.510.611
1.539.385
272
Z-3-14-0
DIAGNOSTIK TIDUR
293.706
302.518
308.392
314.266
273
Z-3-15-0
185.730
191.302
195.017
198.731
274
Z-3-16-0

(MRI)
596.137
614.022
625.944
637.867
275
Z-3-17-0
PENGOBATAN NUKLIR
250.271
257.780
262.785
267.790
276
Z-3-18-0
CT-SCAN KEPALA
241.132
248.366
253.188
258.011
277
Z-3-19-0
CT SCAN LAIN-LAIN
250.971
258.500
263.520
268.539
278
Z-3-20-0
170.692
175.812
179.226
182.640
279
Z-3-21-0
163.172
168.067
171.331
174.594
280
Z-3-22-0
183.962
189.481
193.160
196.839
281
Z-3-23-0
191.612
197.361
201.193
205.025
282
Z-3-24-0
376.480
387.775
395.304
402.834
283
Z-3-25-0
167.684
172.714
176.068
179.422
284
Z-3-26-0
189.516
195.201
198.992
202.782
285
Z-3-27-0
PERAWATAN LUKA
180.936
186.364
189.983
193.602
286
Z-3-28-0
IMAGING PAYUDARA
185.730
191.302
195.017
198.731
287
Z-3-29-0
IMAGING LAIN-LAIN
535.308
551.367
562.073
572.779
288
Z-3-30-0
FOTOTERAPI
90.340
93.050
94.857
96.664
- 487 2. RUMAH SAKIT KUSTAKELAS B NON PENDIDIKAN

a. RawatInap
Tarif INA-CBG (Rp)
No
Kode
INA-CBG
A-4-10-i
SEPTIKEMIA RINGAN
2.174.376
2.239.607
2.283.095
2.326.582
A-4-10-ii
SEPTIKEMIA SEDANG
2.489.076
2.563.749
2.613.530
2.663.312
A-4-10-iii
SEPTIKEMIA BERAT
3.902.402
4.019.474
4.097.522
4.175.570
A-4-11-i
3.907.861
4.025.097
4.103.254
4.181.412
A-4-11-ii
6.037.194
6.218.310
6.339.054
6.459.798
A-4-11-iii
9.875.531
10.171.797
10.369.307
10.566.818
A-4-12-i
DEMAM RINGAN
1.532.986
1.578.975
1.609.635
1.640.295
A-4-12-ii
DEMAM SEDANG
2.198.736
2.264.699
2.308.673
2.352.648
A-4-12-iii
DEMAM BERAT
2.516.293
2.591.781
2.642.107
2.692.433
10
A-4-13-i
1.916.232
1.973.719
2.012.044
2.050.369
11
A-4-13-ii
2.299.479
2.368.463
2.414.453
2.460.442
12
A-4-13-iii
2.794.745
2.878.587
2.934.482
2.990.377
13
A-4-14-i
108.293
111.542
113.708
115.874
14
A-4-14-ii
139.354
143.534
146.321
149.109
15
A-4-14-iii
159.226
164.003
167.187
170.372
16
A-4-15-i
INFEKSI HIV RINGAN
2.299.479
2.368.463
2.414.453
2.460.442
17
A-4-15-ii
INFEKSI HIV SEDANG
3.449.218
3.552.695
3.621.679
3.690.664
18
A-4-15-iii
INFEKSI HIV BERAT
4.797.050
4.940.962
5.036.903
5.132.844
19
B-1-01-i
25.493.308
26.258.107
26.767.974
27.277.840
20
B-1-01-ii
28.125.935
28.969.713
29.532.231
30.094.750
21
B-1-01-iii
49.338.677
50.818.837
51.805.611
52.792.384
22
B-1-10-i
3.305.121
3.404.275
3.470.377
3.536.479
23
B-1-10-ii
8.423.040
8.675.731
8.844.192
9.012.653
24
B-1-10-iii
14.661.180
15.101.015
15.394.239
15.687.463
25
B-1-11-i
2.259.482
2.327.266
2.372.456
2.417.646
26
B-1-11-ii
5.671.513
5.841.658
5.955.088
6.068.519
27
B-1-11-iii
7.110.670
7.323.990
7.466.203
7.608.416
28
B-1-12-i
4.819.556
4.964.143
5.060.534
5.156.925
29
B-1-12-ii
10.329.488
10.639.373
10.845.963
11.052.553
30
B-1-12-iii
12.571.377
12.948.518
13.199.945
13.451.373
Deskripsi (INA-CBG)

RINGAN
SEDANG
BERAT

LAIN-LAIN RINGAN
LAIN-LAIN SEDANG
LAIN-LAIN BERAT

(RINGAN)
(SEDANG)
(BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT
Regional 1
Regional 2
Regional 3
Regional 4
- 488 No
Kode
INA-CBG
31
B-1-13-i
32
B-1-13-ii
33
B-1-13-iii
34
B-1-14-i
35
B-1-14-ii
36
B-1-14-iii
37
B-4-10-i
38
Deskripsi (INA-CBG)
LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.158.148
3.252.892
3.316.055
3.379.218
5.144.165
5.298.490
5.401.373
5.504.256
7.583.942
7.811.461
7.963.140
8.114.818
4.288.543
4.417.199
4.502.970
4.588.741
4.769.725
4.912.817
5.008.211
5.103.606
7.461.668
7.685.518
7.834.751
7.983.985
1.199.364
1.235.345
1.259.332
1.283.320
B-4-10-ii
1.916.232
1.973.719
2.012.044
2.050.369
39
B-4-10-iii
2.929.692
3.017.583
3.076.176
3.134.770
40
B-4-11-i
2.896.934
2.983.842
3.041.780
3.099.719
41
B-4-11-ii
4.404.062
4.536.184
4.624.266
4.712.347
42
B-4-11-iii
4.743.328
4.885.628
4.980.495
5.075.361
43
B-4-12-i
2.541.861
2.618.117
2.668.954
2.719.791
44
B-4-12-ii
3.603.733
3.711.845
3.783.920
3.855.994
45
B-4-12-iii
7.004.179
7.214.304
7.354.388
7.494.471
46
B-4-13-i
2.299.479
2.368.463
2.414.453
2.460.442
47
B-4-13-ii
3.588.463
3.696.117
3.767.886
3.839.655
48
B-4-13-iii
5.446.525
5.609.921
5.718.852
5.827.782
49
B-4-14-i
2.299.479
2.368.463
2.414.453
2.460.442
50
B-4-14-ii
2.682.725
2.763.207
2.816.862
2.870.516
51
B-4-14-iii
3.579.026
3.686.396
3.757.977
3.829.557
52
C-4-10-i
2.239.228
2.306.405
2.351.190
2.395.974
53
C-4-10-ii
4.350.586
4.481.103
4.568.115
4.655.127
54
C-4-10-iii
LEUKEMIA AKUT BERAT
7.281.683
7.500.134
7.645.767
7.791.401
55
C-4-11-i
2.299.479
2.368.463
2.414.453
2.460.442
56
C-4-11-ii
3.065.972
3.157.951
3.219.270
3.280.590
57
C-4-11-iii
5.212.511
5.368.886
5.473.137
5.577.387
58
C-4-12-i
RADIOTERAPI RINGAN
1.532.986
1.578.975
1.609.635
1.640.295
59
C-4-12-ii
RADIOTERAPI SEDANG
4.220.773
4.347.396
4.431.812
4.516.227
60
C-4-12-iii
RADIOTERAPI BERAT
8.569.015
8.826.086
8.997.466
9.168.846
61
C-4-13-i
KEMOTERAPI RINGAN
1.532.986
1.578.975
1.609.635
1.640.295
62
C-4-13-ii
KEMOTERAPI SEDANG
3.065.972
3.157.951
3.219.270
3.280.590
63
C-4-13-iii
KEMOTERAPI BERAT
4.011.597
4.131.945
4.212.177
4.292.409

PANCREAS RINGAN
PANCREAS SEDANG
PANCREAS BERAT
(RINGAN)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT
- 489 No
Kode
INA-CBG
64
C-4-14-i
65
C-4-14-ii
66
C-4-14-iii
67
D-1-10-i
68
D-1-10-ii
69
D-1-10-iii
70
D-1-11-i
71
Deskripsi (INA-CBG)
RINGAN
SEDANG
BERAT
TULANG RINGAN
TULANG SEDANG
TULANG BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.987.873
2.047.509
2.087.266
2.127.024
2.904.806
2.991.951
3.050.047
3.108.143
4.428.293
4.561.142
4.649.708
4.738.274
16.312.788
16.802.172
17.128.428
17.454.683
24.845.628
25.590.997
26.087.909
26.584.822
33.672.615
34.682.793
35.356.245
36.029.698
3.352.953
3.453.542
3.520.601
3.587.660
D-1-11-ii
8.745.118
9.007.471
9.182.374
9.357.276
72
D-1-11-iii
12.390.395
12.762.107
13.009.914
13.257.722
73
D-1-20-i
4.130.132
4.254.036
4.336.638
4.419.241
74
D-1-20-ii
9.292.796
9.571.580
9.757.436
9.943.292
75
D-1-20-iii
16.798.267
17.302.215
17.638.181
17.974.146
76
D-4-10-i
1.472.527
1.516.703
1.546.153
1.575.604
77
D-4-10-ii
2.973.309
3.062.509
3.121.975
3.181.441
78
D-4-10-iii
3.832.465
3.947.439
4.024.088
4.100.737
79
D-4-11-i
3.353.407
3.454.009
3.521.077
3.588.145
80
D-4-11-ii
5.993.440
6.173.243
6.293.112
6.412.981
81
D-4-11-iii
8.205.378
8.451.540
8.615.647
8.779.755
82
D-4-12-i
1.965.689
2.024.660
2.063.973
2.103.287
83
D-4-12-ii
2.726.604
2.808.402
2.862.934
2.917.466
84
D-4-12-iii
4.186.701
4.312.302
4.396.036
4.479.770
85
D-4-13-i
1.532.986
1.578.975
1.609.635
1.640.295
86
D-4-13-ii
2.299.479
2.368.463
2.414.453
2.460.442
87
D-4-13-iii
2.682.725
2.763.207
2.816.862
2.870.516
88
D-4-14-i
1.847.061
1.902.473
1.939.414
1.976.355
89
D-4-14-ii
4.312.436
4.441.809
4.528.058
4.614.306
90
D-4-14-iii
5.144.139
5.298.463
5.401.346
5.504.229
91
E-1-01-i
3.674.729
3.784.971
3.858.466
3.931.960
92
E-1-01-ii
4.813.546
4.957.952
5.054.223
5.150.494
93
E-1-01-iii
10.910.013
11.237.313
11.455.514
11.673.714
94
E-1-10-i
3.744.352
3.856.683
3.931.570
4.006.457
95
E-1-10-ii
4.544.765
4.681.108
4.772.003
4.862.898
96
E-1-10-iii
9.579.026
9.866.397
10.057.978
10.249.558


RINGAN
SEDANG
BERAT
- 490 No
Kode
INA-CBG
97
E-1-20-i
98
E-1-20-ii
99
E-1-20-iii
100
E-4-10-i
101
E-4-10-ii
102
E-4-10-iii
103
E-4-11-i
104
E-4-11-ii
105
E-4-11-iii
106
E-4-12-i
107
E-4-12-ii
108
E-4-12-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.336.038
4.466.119
4.552.840
4.639.560
5.807.422
5.981.644
6.097.793
6.213.941
12.867.606
13.253.634
13.510.986
13.768.338
1.916.232
1.973.719
2.012.044
2.050.369
2.725.286
2.807.044
2.861.550
2.916.056
5.209.330
5.365.610
5.469.797
5.573.983
1.634.947
1.683.995
1.716.694
1.749.393
3.093.039
3.185.830
3.247.691
3.309.552
5.100.564
5.253.581
5.355.592
5.457.603
1.953.533
2.012.139
2.051.210
2.090.281
3.393.655
3.495.465
3.563.338
3.631.211
5.541.579
5.707.827
5.818.658
5.929.490
2.060.595
2.122.413
2.163.625
2.204.837
3.538.056
3.644.198
3.714.959
3.785.720
6.121.731
6.305.383
6.427.818
6.550.252
GANGGUAN KELENJAR ENDOKRIN LAINLAIN RINGAN

GANGGUAN KELENJAR ENDOKRIN LAINLAIN SEDANG
GANGGUAN KELENJAR ENDOKRIN LAINLAIN BERAT
109
E-4-13-i
110
E-4-13-ii
111
E-4-13-iii
112
F-4-10-i
SCHIZOFRENIA RINGAN
2.519.467
2.595.051
2.645.441
2.695.830
113
F-4-10-ii
SCHIZOFRENIA SEDANG
2.797.950
2.881.888
2.937.847
2.993.806
114
F-4-10-iii
SCHIZOFRENIA BERAT
4.142.426
4.266.699
4.349.547
4.432.396
115
F-4-11-i
2.322.339
2.392.009
2.438.456
2.484.902
116
F-4-11-ii
2.705.745
2.786.917
2.841.032
2.895.147
117
F-4-11-iii
DEPRESI MAYOR BERAT
3.469.754
3.573.847
3.643.242
3.712.637
1.149.739
1.184.232
1.207.226
1.230.221
1.641.665
1.690.915
1.723.748
1.756.581
3.561.316
3.668.156
3.739.382
3.810.609

IMPULSE RINGAN
IMPULSE SEDANG
IMPULSE BERAT
118
F-4-12-i
119
F-4-12-ii
120
F-4-12-iii
121
F-4-13-i
1.876.802
1.933.107
1.970.643
2.008.179
122
F-4-13-ii
2.485.369
2.559.930
2.609.637
2.659.345
123
F-4-13-iii
3.204.566
3.300.703
3.364.794
3.428.885
124
F-4-14-i
DEPRESI RINGAN
1.313.762
1.353.175
1.379.450
1.405.725
125
F-4-14-ii
DEPRESI SEDANG
1.685.166
1.735.721
1.769.424
1.803.127
126
F-4-14-iii
DEPRESI BERAT
2.267.466
2.335.490
2.380.839
2.426.188
127
F-4-15-i
1.561.988
1.608.848
1.640.087
1.671.327
128
F-4-15-ii
2.299.479
2.368.463
2.414.453
2.460.442
129
F-4-15-iii
3.028.555
3.119.411
3.179.982
3.240.554
- 491 No
Kode
INA-CBG
130
F-4-16-i
131
F-4-16-ii
132
F-4-16-iii
133
F-4-17-i
134
F-4-17-ii
135
F-4-17-iii
136
F-4-18-i
137
Deskripsi (INA-CBG)
RINGAN
SEDANG
BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.364.216
3.465.143
3.532.427
3.599.712
3.910.817
4.028.142
4.106.358
4.184.575
5.220.288
5.376.897
5.481.303
5.585.708
776.758
800.060
815.596
831.131
2.276.603
2.344.901
2.390.433
2.435.965
2.428.968
2.501.837
2.550.416
2.598.996
2.915.989
3.003.469
3.061.789
3.120.109
F-4-18-ii
3.208.412
3.304.664
3.368.833
3.433.001
138
F-4-18-iii
4.946.047
5.094.428
5.193.349
5.292.270
139
F-4-19-i
2.236.289
2.303.377
2.348.103
2.392.829
140
F-4-19-ii
2.863.625
2.949.534
3.006.807
3.064.079
141
F-4-19-iii
3.565.252
3.672.209
3.743.514
3.814.819
142
G-1-01-i
7.109.639
7.322.928
7.465.121
7.607.314
143
G-1-01-ii
12.033.921
12.394.938
12.635.617
12.876.295
144
G-1-01-iii
23.296.327
23.995.216
24.461.143
24.927.069
145
G-1-10-i
3.548.069
3.654.511
3.725.472
3.796.433
146
G-1-10-ii
5.008.991
5.159.260
5.259.440
5.359.620
147
G-1-10-iii
5.936.724
6.114.826
6.233.560
6.352.294
148
G-1-11-i
4.092.803
4.215.587
4.297.443
4.379.299
149
G-1-11-ii
8.404.879
8.657.026
8.825.123
8.993.221
150
G-1-11-iii
17.599.053
18.127.024
18.479.005
18.830.986
151
G-1-12-i
3.182.995
3.278.485
3.342.145
3.405.804
152
G-1-12-ii
7.287.150
7.505.764
7.651.507
7.797.250
153
G-1-12-iii
12.852.934
13.238.522
13.495.581
13.752.639
154
G-1-13-i
839.455
864.639
881.428
898.217
155
G-1-13-ii
2.254.684
2.322.324
2.367.418
2.412.512
156
G-1-13-iii
5.087.516
5.240.142
5.341.892
5.443.642
157
G-1-20-i
4.010.844
4.131.169
4.211.386
4.291.603
158
G-1-20-ii
5.418.782
5.581.345
5.689.721
5.798.097
159
G-1-20-iii
13.267.250
13.665.268
13.930.613
14.195.958
160
G-1-30-i
5.115.471
5.268.935
5.371.244
5.473.554
161
G-1-30-ii
13.351.869
13.752.425
14.019.463
14.286.500
162
G-1-30-iii
17.187.982
17.703.621
18.047.381
18.391.140

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT
RINGAN
SEDANG
RINGAN
SEDANG
BERAT
- 492 No
Kode
INA-CBG
163
G-4-10-i
164
G-4-10-ii
165
G-4-10-iii
166
G-4-11-i
167
G-4-11-ii
168
G-4-11-iii
169
G-4-12-i
170
G-4-12-ii
171
G-4-12-iii
172
G-4-13-i
173
G-4-13-ii
174
G-4-13-iii
175
G-4-14-i
176
G-4-14-ii
177
G-4-14-iii
178
G-4-15-i
179
G-4-15-ii
180
G-4-15-iii
181
G-4-16-i
182
Deskripsi (INA-CBG)
BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
DEGENERATIF RINGAN
DEGENERATIF SEDANG
DEGENERATIF BERAT
RINGAN
SEDANG
BERAT
TRAUMATIK RINGAN
TRAUMATIK SEDANG
TRAUMATIK BERAT
DENGAN INFARK BERAT
NON SPESIFIK & PENYUMBATAN PRECEREBRAL TANPA INFARK RINGAN
NON SPESIFIK & PENYUMBATAN PRECEREBRAL TANPA INFARK SEDANG
NON SPESIFIK & PENYUMBATAN PRECEREBRAL TANPA INFARK BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.299.479
2.368.463
2.414.453
2.460.442
2.682.725
2.763.207
2.816.862
2.870.516
4.098.460
4.221.414
4.303.383
4.385.353
3.793.975
3.907.795
3.983.674
4.059.554
4.401.011
4.533.042
4.621.062
4.709.082
6.449.758
6.643.251
6.772.246
6.901.241
2.837.560
2.922.686
2.979.438
3.036.189
3.575.325
3.682.585
3.754.091
3.825.598
5.192.734
5.348.516
5.452.371
5.556.226
1.578.799
1.626.163
1.657.739
1.689.315
2.682.725
2.763.207
2.816.862
2.870.516
3.171.362
3.266.503
3.329.930
3.393.358
2.887.388
2.974.010
3.031.758
3.089.506
4.750.728
4.893.250
4.988.265
5.083.279
5.948.020
6.126.461
6.245.421
6.364.381
2.955.326
3.043.986
3.103.092
3.162.199
3.571.068
3.678.200
3.749.622
3.821.043
4.412.866
4.545.252
4.633.510
4.721.767
1.916.232
1.973.719
2.012.044
2.050.369
G-4-16-ii
2.865.743
2.951.715
3.009.030
3.066.345
183
G-4-16-iii
5.200.811
5.356.836
5.460.852
5.564.868
184
G-4-17-i
2.738.471
2.820.625
2.875.395
2.930.164
185
G-4-17-ii
3.398.563
3.500.520
3.568.492
3.636.463
186
G-4-17-iii
5.696.020
5.866.901
5.980.821
6.094.742
187
G-4-18-i
2.299.479
2.368.463
2.414.453
2.460.442
188
G-4-18-ii
3.297.055
3.395.966
3.461.907
3.527.848
189
G-4-18-iii
3.492.894
3.597.681
3.667.538
3.737.396
190
G-4-19-i
1.916.232
1.973.719
2.012.044
2.050.369
191
G-4-19-ii
3.883.503
4.000.008
4.077.678
4.155.348

PERIFER RINGAN
PERIFER SEDANG
PERIFER BERAT
PERSARAFAN RINGAN
PERSARAFAN SEDANG
PERSARAFAN BERAT
RINGAN
SEDANG
- 493 Tarif INA-CBG (Rp)
No
Kode
INA-CBG
192
G-4-19-iii

BERAT
5.792.953
5.966.742
6.082.601
6.198.460
193
G-4-20-i
1.341.363
1.381.604
1.408.431
1.435.258
194
G-4-20-ii
1.904.736
1.961.879
1.999.973
2.038.068
195
G-4-20-iii
3.248.022
3.345.463
3.410.423
3.475.383
196
G-4-21-i
1.554.333
1.600.963
1.632.049
1.663.136
197
G-4-21-ii
3.219.178
3.315.754
3.380.137
3.444.521
198
G-4-21-iii
3.792.572
3.906.349
3.982.200
4.058.052
199
G-4-22-i
1.532.986
1.578.975
1.609.635
1.640.295
200
G-4-22-ii
1.916.232
1.973.719
2.012.044
2.050.369
201
G-4-22-iii
2.198.419
2.264.372
2.308.340
2.352.309
202
G-4-23-i
1.532.986
1.578.975
1.609.635
1.640.295
203
G-4-23-ii
1.916.232
1.973.719
2.012.044
2.050.369
204
G-4-23-iii
2.739.118
2.821.292
2.876.074
2.930.857
205
G-4-24-i
1.532.986
1.578.975
1.609.635
1.640.295
206
G-4-24-ii
1.916.232
1.973.719
2.012.044
2.050.369
207
G-4-24-iii
TRAUMA KEPALA BERAT
4.026.755
4.147.558
4.228.093
4.308.628
208
G-4-25-i
GEGAR OTAK RINGAN
1.456.636
1.500.335
1.529.468
1.558.600
209
G-4-25-ii
GEGAR OTAK SEDANG
1.833.937
1.888.955
1.925.634
1.962.312
210
G-4-25-iii
GEGAR OTAK BERAT
2.392.780
2.464.564
2.512.419
2.560.275
2.299.479
2.368.463
2.414.453
2.460.442
2.682.725
2.763.207
2.816.862
2.870.516
5.120.947
5.274.576
5.376.995
5.479.414
2.203.501
2.269.606
2.313.676
2.357.746
4.018.334
4.138.884
4.219.250
4.299.617
5.464.683
5.628.623
5.737.917
5.847.211
2.157.437
2.222.161
2.265.309
2.308.458
2.459.479
2.533.263
2.582.453
2.631.642
4.103.551
4.226.658
4.308.729
4.390.800
Deskripsi (INA-CBG)

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
RINGAN
SEDANG
Regional 1
Regional 2
Regional 3
Regional 4
211
G-4-26-i
212
G-4-26-ii
213
G-4-26-iii
214
H-1-20-i
215
H-1-20-ii
216
H-1-20-iii
217
H-1-30-i
218
H-1-30-ii
219
H-1-30-iii
220
H-4-10-i
2.299.479
2.368.463
2.414.453
2.460.442
221
H-4-10-ii
3.832.465
3.947.439
4.024.088
4.100.737
222
H-4-10-iii
6.248.049
6.435.491
6.560.452
6.685.413
223
H-4-11-i
1.565.692
1.612.663
1.643.977
1.675.291
224
H-4-11-ii
1.749.428
1.801.911
1.836.900
1.871.888

RINGAN
SEDANG
BERAT
No
Kode
INA-CBG
225
H-4-11-iii
2.501.519
2.576.564
2.626.595
2.676.625
226
H-4-12-i
2.172.336
2.237.506
2.280.952
2.324.399
227
H-4-12-ii
2.942.571
3.030.848
3.089.699
3.148.551
228
H-4-12-iii
4.909.479
5.056.763
5.154.953
5.253.142
33.072.334
34.064.505
34.725.951
35.387.398
33.800.098
34.814.101
35.490.103
36.166.105
53.352.807
54.953.391
56.020.447
57.087.503
18.348.341
18.898.791
19.265.758
19.632.725
23.669.359
24.379.440
24.852.827
25.326.215
29.173.862
30.049.078
30.632.555
31.216.032
11.299.561
11.638.548
11.864.539
12.090.530
15.487.993
15.952.633
16.262.393
16.572.153
22.715.724
23.397.195
23.851.510
24.305.824
13.785.133
14.198.687
14.474.390
14.750.093
17.707.248
18.238.466
18.592.611
18.946.756
37.748.177
38.880.622
39.635.586
40.390.550
24.284.569
25.013.106
25.498.797
25.984.488
29.141.482
30.015.727
30.598.556
31.181.386
40.098.496
41.301.451
42.103.420
42.905.390
Deskripsi (INA-CBG)
PROSEDUR TRANPLANTASI PARU

ATAU/DAN JANTUNG RINGAN
ATAU/DAN JANTUNG SEDANG
ATAU/DAN JANTUNG BERAT
KATETERISASI RINGAN
KATETERISASI SEDANG
KATETERISASI BERAT
RINGAN
SEDANG
PROSEDUR PEMBEDAHAN BYPASS
PEMBULUH KORONER DENGAN
Regional 1
Regional 2
Regional 3
Regional 4
229
I-1-01-i
230
I-1-01-ii
231
I-1-01-iii
232
I-1-02-i
233
I-1-02-ii
234
I-1-02-iii
235
I-1-03-i
236
I-1-03-ii
237
I-1-03-iii
238
I-1-04-i
239
I-1-04-ii
240
I-1-04-iii
241
I-1-05-i
242
I-1-05-ii
243
I-1-05-iii
244
I-1-06-i
11.447.207
11.790.623
12.019.567
12.248.511
245
I-1-06-ii
17.276.553
17.794.849
18.140.380
18.485.911
246
I-1-06-iii
22.241.100
22.908.333
23.353.155
23.797.977
247
I-1-07-i
15.053.944
15.505.562
15.806.641
16.107.720
248
I-1-07-ii
18.572.098
19.129.261
19.500.703
19.872.145
249
I-1-07-iii
20.262.038
20.869.899
21.275.140
21.680.381
250
I-1-11-i
2.863.627
2.949.536
3.006.809
3.064.081
251
I-1-11-ii
3.184.067
3.279.589
3.343.270
3.406.952
252
I-1-11-iii
4.237.023
4.364.134
4.448.874
4.533.614

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
RINGAN
SEDANG
BERAT
- 495 No
Kode
INA-CBG
253
I-1-12-i
254
I-1-12-ii
255
I-1-12-iii
256
I-1-13-i
257
I-1-13-ii
258
I-1-13-iii
259
I-1-14-i
260
I-1-14-ii
261
I-1-14-iii
262
I-1-15-i
263
I-1-15-ii
264
I-1-15-iii
Deskripsi (INA-CBG)
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
8.776.530
9.039.825
9.215.356
9.390.887
12.177.845
12.543.180
12.786.737
13.030.294
16.985.218
17.494.775
17.834.479
18.174.184
5.162.664
5.317.544
5.420.798
5.524.051
6.006.444
6.186.637
6.306.766
6.426.895
10.949.345
11.277.826
11.496.813
11.715.799
18.887.998
19.454.638
19.832.398
20.210.158
23.475.083
24.179.335
24.648.837
25.118.339
30.760.453
31.683.267
32.298.476
32.913.685
3.701.142
3.812.176
3.886.199
3.960.222
10.841.595
11.166.843
11.383.675
11.600.507
56.117.717
57.801.248
58.923.602
60.045.957
8.094.856
8.337.702
8.499.599
8.661.496
21.046.626
21.678.025
22.098.957
22.519.890
24.276.767
25.005.070
25.490.605
25.976.140
2.596.085
2.673.968
2.725.890
2.777.811
5.377.434
5.538.757
5.646.306
5.753.855
31.175.092
32.110.345
32.733.847
33.357.349
3.097.599
3.190.527
3.252.478
3.314.430
5.575.677
5.742.948
5.854.461
5.965.975
7.434.237
7.657.264
7.805.949
7.954.633
9.183.656
9.459.166
9.642.839
9.826.512
19.103.861
19.676.976
20.059.054
20.441.131
29.604.045
30.492.167
31.084.248
31.676.329
12.349.948
12.720.446
12.967.445
13.214.444
17.151.424
17.665.967
18.008.996
18.352.024
21.491.521
22.136.267
22.566.097
22.995.927

PROSEDUR LIGASI DAN STRIPPING
PEMBULUH DARAH VENA RINGAN
PEMBULUH DARAH VENA SEDANG
PEMBULUH DARAH VENA BERAT
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
265
I-1-16-i
266
I-1-16-ii
267
I-1-16-iii
268
I-1-17-i
269
I-1-17-ii
270
I-1-17-iii
271
I-1-20-i
272
I-1-20-ii
273
I-1-20-iii
274
I-1-30-i
275
I-1-30-ii
276
I-1-30-iii
277
I-1-40-i
278
I-1-40-ii
279
I-1-40-iii
280
I-4-10-i
3.591.724
3.699.475
3.771.310
3.843.144
281
I-4-10-ii
5.671.396
5.841.538
5.954.966
6.068.394
- 496 No
Kode
INA-CBG
282
I-4-10-iii
Deskripsi (INA-CBG)
ENDOKARDITIS AKUT DAN SUBAKUT
RINGAN
SEDANG
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
8.181.483
8.426.928
8.590.558
8.754.187
4.258.845
4.386.610
4.471.787
4.556.964
5.270.337
5.428.447
5.533.854
5.639.261
283
I-4-11-i
284
I-4-11-ii
285
I-4-11-iii
9.327.246
9.607.063
9.793.608
9.980.153
286
I-4-12-i
3.730.305
3.842.215
3.916.821
3.991.427
287
I-4-12-ii
5.323.135
5.482.829
5.589.292
5.695.755
288
I-4-12-iii
6.457.712
6.651.443
6.780.598
6.909.752
289
I-4-13-i
3.350.840
3.451.365
3.518.382
3.585.399
290
I-4-13-ii
4.868.086
5.014.129
5.111.491
5.208.852
291
I-4-13-iii
9.964.408
10.263.341
10.462.629
10.661.917
292
I-4-14-i
2.083.913
2.146.430
2.188.108
2.229.787
293
I-4-14-ii
2.438.486
2.511.641
2.560.410
2.609.180
294
I-4-14-iii
3.778.842
3.892.208
3.967.784
4.043.361
295
I-4-15-i
3.065.972
3.157.951
3.219.270
3.280.590
296
I-4-15-ii
4.389.090
4.520.763
4.608.545
4.696.327
297
I-4-15-iii
5.002.507
5.152.582
5.252.633
5.352.683
298
I-4-16-i
2.299.479
2.368.463
2.414.453
2.460.442
299
I-4-16-ii
3.726.663
3.838.463
3.912.996
3.987.530
300
I-4-16-iii
4.694.934
4.835.782
4.929.681
5.023.579
301
I-4-17-i
HIPERTENSI RINGAN
2.057.986
2.119.726
2.160.885
2.202.045
302
I-4-17-ii
HIPERTENSI SEDANG
2.914.313
3.001.742
3.060.029
3.118.315
303
I-4-17-iii
HIPERTENSI BERAT
3.545.401
3.651.763
3.722.671
3.793.579
304
I-4-18-i
3.030.822
3.121.747
3.182.363
3.242.980
305
I-4-18-ii
4.643.017
4.782.307
4.875.168
4.968.028
306
I-4-18-iii
6.259.531
6.447.317
6.572.507
6.697.698
307
I-4-19-i
2.372.016
2.443.176
2.490.616
2.538.057
308
I-4-19-ii
3.885.287
4.001.846
4.079.552
4.157.257
309
I-4-19-iii
4.631.227
4.770.164
4.862.788
4.955.413
310
I-4-20-i
2.878.777
2.965.140
3.022.716
3.080.291
311
I-4-20-ii
3.316.566
3.416.063
3.482.394
3.548.726
312
I-4-20-iii
4.401.635
4.533.684
4.621.717
4.709.750
313
I-4-21-i
3.828.307
3.943.157
4.019.723
4.096.289
314
I-4-21-ii
4.775.565
4.918.832
5.014.343
5.109.855
THROMBOPHLEBITIS PADA PEMBULUH

DARAH VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
CARDIAC ARREST, TIDAK DIKETAHUI
RINGAN
SEDANG
GANGUAN PEMBULUH DARAH PERIFER
LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)

RINGAN
SEDANG
KONGENITAL BERAT
GANGGUAN KONDUKSI & ARITMIA
JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
ANGINA PEKTORIS DAN NYERI DADA
RINGAN
SEDANG
No
Kode
INA-CBG
315
I-4-21-iii
6.514.883
6.710.330
6.840.628
6.970.925
316
I-4-22-i
2.491.102
2.565.835
2.615.657
2.665.479
317
I-4-22-ii
2.870.495
2.956.610
3.014.020
3.071.430
318
I-4-22-iii
4.187.975
4.313.614
4.397.373
4.481.133
1.887.150
1.943.765
1.981.508
2.019.251
2.316.986
2.386.495
2.432.835
2.479.175
4.527.179
4.662.994
4.753.538
4.844.081
2.250.825
2.318.350
2.363.367
2.408.383
5.619.688
5.788.279
5.900.673
6.013.067
7.105.081
7.318.233
7.460.335
7.602.436
18.485.086
19.039.639
19.409.341
19.779.042
20.134.391
20.738.423
21.141.111
21.543.799
33.098.388
34.091.340
34.753.307
35.415.275
9.269.848
9.547.943
9.733.340
9.918.737
9.930.477
10.228.391
10.427.001
10.625.610
14.674.415
15.114.648
15.408.136
15.701.624
3.617.229
3.725.746
3.798.090
3.870.435
8.736.922
8.999.029
9.173.768
9.348.506
15.469.794
15.933.887
16.243.283
16.552.679
3.126.443
3.220.236
3.282.765
3.345.294
4.547.164
4.683.579
4.774.523
4.865.466
6.837.531
7.042.657
7.179.407
7.316.158
2.108.333
2.171.583
2.213.750
2.255.916
10.325.329
10.635.089
10.841.595
11.048.102
31.140.739
32.074.961
32.697.776
33.320.590
Deskripsi (INA-CBG)

RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
Regional 1
Regional 2
Regional 3
Regional 4
319
I-4-23-i
320
I-4-23-ii
321
I-4-23-iii
322
I-4-24-i
323
I-4-24-ii
324
I-4-24-iii
325
J-1-01-i
326
J-1-01-ii
327
J-1-01-iii
328
J-1-02-i
329
J-1-02-ii
330
J-1-02-iii
331
J-1-10-i
332
J-1-10-ii
333
J-1-10-iii
334
J-1-20-i
335
J-1-20-ii
336
J-1-20-iii
337
J-1-30-i
338
J-1-30-ii
339
J-1-30-iii
340
J-4-10-i
2.433.298
2.506.297
2.554.963
2.603.629
341
J-4-10-ii
3.479.324
3.583.703
3.653.290
3.722.876
342
J-4-10-iii
5.263.697
5.421.608
5.526.882
5.632.156
343
J-4-11-i
1.535.101
1.581.154
1.611.857
1.642.559
344
J-4-11-ii
2.136.826
2.200.931
2.243.667
2.286.404
345
J-4-11-iii
3.062.126
3.153.990
3.215.233
3.276.475
No
Kode
INA-CBG
346
J-4-12-i
EMBOLI PARU RINGAN
2.347.569
2.417.996
2.464.947
2.511.899
347
J-4-12-ii
EMBOLI PARU SEDANG
3.040.021
3.131.222
3.192.022
3.252.823
348
J-4-12-iii
EMBOLI PARU BERAT
4.059.641
4.181.430
4.262.623
4.343.816
349
J-4-13-i
3.616.147
3.724.632
3.796.955
3.869.278
350
J-4-13-ii
5.315.737
5.475.209
5.581.523
5.687.838
351
J-4-13-iii
8.642.592
8.901.870
9.074.722
9.247.574
352
J-4-14-i
TUMOR PARU RINGAN
2.464.290
2.538.219
2.587.505
2.636.790
353
J-4-14-ii
TUMOR PARU SEDANG
4.128.023
4.251.864
4.334.424
4.416.985
354
J-4-14-iii
TUMOR PARU BERAT
4.908.010
5.055.250
5.153.410
5.251.571
2.299.479
2.368.463
2.414.453
2.460.442
4.161.244
4.286.081
4.369.306
4.452.531
5.199.391
5.355.373
5.459.361
5.563.348
1.916.232
1.973.719
2.012.044
2.050.369
2.682.725
2.763.207
2.816.862
2.870.516
4.839.354
4.984.535
5.081.322
5.178.109
2.393.078
2.464.870
2.512.732
2.560.593
3.233.459
3.330.463
3.395.132
3.459.802
Deskripsi (INA-CBG)

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
Regional 1
Regional 2
Regional 3
Regional 4
355
J-4-15-i
356
J-4-15-ii
357
J-4-15-iii
358
J-4-16-i
359
J-4-16-ii
360
J-4-16-iii
361
J-4-17-i
362
J-4-17-ii
363
J-4-17-iii
4.227.460
4.354.283
4.438.833
4.523.382
364
J-4-18-i
2.153.093
2.217.686
2.260.748
2.303.809
365
J-4-18-ii
2.997.968
3.087.907
3.147.866
3.207.825
366
J-4-18-iii
3.109.555
3.202.842
3.265.033
3.327.224
367
J-4-19-i
2.682.725
2.763.207
2.816.862
2.870.516
368
J-4-19-ii
3.065.972
3.157.951
3.219.270
3.280.590
369
J-4-19-iii
4.803.204
4.947.300
5.043.365
5.139.429
2.682.725
2.763.207
2.816.862
2.870.516
3.272.429
3.370.602
3.436.051
3.501.499
7.394.510
7.616.345
7.764.236
7.912.126
1.532.986
1.578.975
1.609.635
1.640.295
3.782.156
3.895.621
3.971.264
4.046.907
5.394.592
5.556.429
5.664.321
5.772.213
4.130.132
4.254.036
4.336.638
4.419.241
5.763.870
5.936.786
6.052.063
6.167.341
6.750.484
6.952.999
7.088.008
7.223.018
370
J-4-20-i
371
J-4-20-ii
372
J-4-20-iii
373
J-4-21-i
374
J-4-21-ii
375
J-4-21-iii
376
K-1-10-i
377
K-1-10-ii
378
K-1-10-iii
PLEURAL EFUSI DAN PNEUMOTORAK

RINGAN
SEDANG
USUS BESAR (RINGAN)
USUS BESAR (SEDANG)
USUS BESAR (BERAT)
- 499 No
Kode
INA-CBG
379
K-1-11-i
380
K-1-11-ii
381
K-1-11-iii
382
K-1-12-i
383
K-1-12-ii
384
K-1-12-iii
385
K-1-13-i
386
Deskripsi (INA-CBG)
RINGAN
SEDANG
BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.551.278
3.657.816
3.728.842
3.799.867
4.662.399
4.802.271
4.895.519
4.988.767
11.832.252
12.187.219
12.423.864
12.660.509
1.910.316
1.967.625
2.005.831
2.044.038
2.489.732
2.564.424
2.614.219
2.664.014
4.952.601
5.101.179
5.200.231
5.299.283
2.169.857
2.234.953
2.278.350
2.321.747
K-1-13-ii
3.790.117
3.903.820
3.979.622
4.055.425
387
K-1-13-iii
4.053.393
4.174.995
4.256.063
4.337.130
388
K-1-14-i
3.506.617
3.611.816
3.681.948
3.752.080
389
K-1-14-ii
4.118.919
4.242.487
4.324.865
4.407.243
390
K-1-14-iii
10.141.973
10.446.232
10.649.071
10.851.911
391
K-1-20-i
6.803.866
7.007.982
7.144.059
7.280.136
392
K-1-20-ii
9.496.402
9.781.294
9.971.222
10.161.150
393
K-1-20-iii
20.284.764
20.893.307
21.299.002
21.704.697
4.478.643
4.613.002
4.702.575
4.792.148
8.260.263
8.508.071
8.673.276
8.838.482
12.864.300
13.250.229
13.507.515
13.764.801
4.499.338
4.634.318
4.724.304
4.814.291
4.951.074
5.099.606
5.198.628
5.297.649
8.210.880
8.457.206
8.621.424
8.785.641
PROSEDUR HERNIA INGUINAL DAN

FEMORAL RINGAN
FEMORAL SEDANG
FEMORAL BERAT

(RINGAN)
(SEDANG)
(BERAT)
394
K-1-30-i
395
K-1-30-ii
396
K-1-30-iii
397
K-1-40-i
398
K-1-40-ii
399
K-1-40-iii
400
K-1-50-i
3.431.909
3.534.866
3.603.504
3.672.143
401
K-1-50-ii
4.444.484
4.577.819
4.666.708
4.755.598
402
K-1-50-iii
PROSEDUR ANAL BERAT
6.309.985
6.499.285
6.625.485
6.751.684
403
K-4-10-i
2.599.424
2.677.407
2.729.395
2.781.384
404
K-4-10-ii
3.110.364
3.203.675
3.265.882
3.328.089
405
K-4-10-iii
12.879.976
13.266.375
13.523.975
13.781.574
406
K-4-11-i
1.532.986
1.578.975
1.609.635
1.640.295
407
K-4-11-ii
2.299.479
2.368.463
2.414.453
2.460.442
408
K-4-11-iii
4.178.982
4.304.351
4.387.931
4.471.510
409
K-4-12-i
1.532.986
1.578.975
1.609.635
1.640.295
410
K-4-12-ii
2.290.257
2.358.965
2.404.770
2.450.575
411
K-4-12-iii
5.496.454
5.661.348
5.771.277
5.881.206
- 500 No
Kode
INA-CBG
412
K-4-13-i
413
K-4-13-ii
414
K-4-13-iii
415
K-4-14-i
416
K-4-14-ii
417
K-4-14-iii
418
K-4-15-i
419
K-4-15-ii
420
K-4-15-iii
421
K-4-16-i
422
K-4-16-ii
423
K-4-16-iii
424
K-4-17-i
425
K-4-17-ii
426
K-4-17-iii
427
K-4-18-i
428
K-4-18-ii
429
K-4-18-iii
430
L-1-20-i
431
L-1-20-ii
432
L-1-20-iii
433
L-1-30-i
434
L-1-30-ii
435
L-1-30-iii
436
L-1-40-i
437
L-1-40-ii
438
L-1-40-iii
439
L-1-50-i
440
441
Deskripsi (INA-CBG)
(RINGAN)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT
INFEKSI-INFEKSI GASTROINTESTINAL
RINGAN
SEDANG
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.299.479
2.368.463
2.414.453
2.460.442
2.978.391
3.067.743
3.127.311
3.186.879
4.871.345
5.017.485
5.114.912
5.212.339
1.916.232
1.973.719
2.012.044
2.050.369
2.593.421
2.671.223
2.723.092
2.774.960
3.922.796
4.040.480
4.118.936
4.197.392
1.916.232
1.973.719
2.012.044
2.050.369
3.603.040
3.711.131
3.783.192
3.855.252
5.126.477
5.280.271
5.382.801
5.485.330
1.916.232
1.973.719
2.012.044
2.050.369
2.299.479
2.368.463
2.414.453
2.460.442
2.806.813
2.891.017
2.947.153
3.003.290
1.532.986
1.578.975
1.609.635
1.640.295
2.236.655
2.303.755
2.348.488
2.393.221
2.976.760
3.066.062
3.125.598
3.185.133
1.532.986
1.578.975
1.609.635
1.640.295
2.379.830
2.451.225
2.498.822
2.546.418
2.815.327
2.899.787
2.956.093
3.012.400
15.687.430
16.158.053
16.471.802
16.785.550
16.319.252
16.808.829
17.135.214
17.461.600
25.002.978
25.753.067
26.253.127
26.753.186
502.644
517.723
527.776
537.829
728.081
749.923
764.485
779.047
767.898
790.935
806.293
821.651
202.953
209.041
213.100
217.160
456.786
470.490
479.625
488.761
774.131
797.355
812.838
828.321
5.162.664
5.317.544
5.420.798
5.524.051
L-1-50-ii
9.292.796
9.571.580
9.757.436
9.943.292
L-1-50-iii
11.236.305
11.573.394
11.798.120
12.022.847

(RINGAN)
(SEDANG)
(BERAT)
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
PROSEDUR PEMINDAHAN KULIT TANPA
LUKA BAKAR RINGAN
LUKA BAKAR SEDANG
LUKA BAKAR BERAT
No
Kode
INA-CBG
442
L-4-10-i
162.440
167.313
170.562
173.811
443
L-4-10-ii
189.513
195.199
198.989
202.779
444
L-4-10-iii
383.369
394.870
402.538
410.205
445
L-4-11-i
2.174.888
2.240.135
2.283.633
2.327.130
446
L-4-11-ii
2.979.559
3.068.946
3.128.537
3.188.128
447
L-4-11-iii
8.080.191
8.322.597
8.484.200
8.645.804
448
L-4-12-i
162.440
167.313
170.562
173.811
449
L-4-12-ii
238.337
245.487
250.254
255.021
450
L-4-12-iii
399.663
411.653
419.646
427.640
1.443.313
1.486.613
1.515.479
1.544.345
1.664.226
1.714.152
1.747.437
1.780.721
2.496.468
2.571.362
2.621.292
2.671.221
108.293
111.542
113.708
115.874
162.440
167.313
170.562
173.811
253.978
261.597
266.677
271.756
527.972
543.811
554.371
564.930
589.302
606.981
618.767
630.553
827.810
852.644
869.201
885.757
Deskripsi (INA-CBG)

GANGGUAN PADA KULIT & PAYUDARA
LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
Regional 1
Regional 2
Regional 3
Regional 4
451
L-4-13-i
452
L-4-13-ii
453
L-4-13-iii
454
L-4-14-i
455
L-4-14-ii
456
L-4-14-iii
457
M-1-01-i
458
M-1-01-ii
459
M-1-01-iii
460
M-1-02-i
337.302
347.421
354.167
360.913
461
M-1-02-ii
553.786
570.399
581.475
592.551
462
M-1-02-iii
1.002.881
1.032.967
1.053.025
1.073.082
463
M-1-03-i
906.283
933.472
951.598
969.723
464
M-1-03-ii
1.088.576
1.121.233
1.143.005
1.164.776
465
M-1-03-iii
1.130.574
1.164.491
1.187.103
1.209.714
466
M-1-04-i
222.508
229.183
233.633
238.084
467
M-1-04-ii
285.253
293.811
299.516
305.221
468
M-1-04-iii
356.940
367.649
374.787
381.926
469
M-1-05-i
346.625
357.024
363.956
370.889
470
M-1-05-ii
400.605
412.624
420.636
428.648
471
M-1-05-iii
682.340
702.810
716.457
730.104
472
M-1-07-i
424.185
436.911
445.394
453.878

PROSEDUR PADA SENDI
TUNGKAI/ANGGOTA TUBUH BAGIAN
BAWAH MAYOR (RINGAN)
PROSEDUR PADA SENDI
BAWAH MAYOR (SEDANG)
PROSEDUR PADA SENDI
BAWAH MAYOR (BERAT)
- 502 No
Kode
INA-CBG
473
M-1-07-ii
474
M-1-07-iii
475
M-1-10-i
476
M-1-10-ii
477
M-1-10-iii
478
M-1-20-i
479
M-1-20-ii
480
M-1-20-iii
481
M-1-30-i
482
Deskripsi (INA-CBG)
LENGKUNGAN TULANG BELAKANG
SEDANG
TULANG WAJAH RINGAN
TULANG WAJAH SEDANG
TULANG WAJAH BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
568.275
585.324
596.689
608.055
1.157.631
1.192.360
1.215.512
1.238.665
239.133
246.307
251.090
255.873
888.614
915.272
933.044
950.817
1.108.402
1.141.654
1.163.822
1.185.990
236.565
243.662
248.393
253.124
337.390
347.512
354.260
361.008
656.367
676.058
689.185
702.312
141.501
145.746
148.576
151.406
M-1-30-ii
292.377
301.149
306.996
312.844
483
M-1-30-iii
PROSEDUR KAKI BERAT
436.165
449.250
457.973
466.697
484
M-1-40-i
158.506
163.261
166.431
169.601
485
M-1-40-ii
291.761
300.514
306.349
312.184
486
M-1-40-iii
510.582
525.899
536.111
546.323
487
M-1-50-i
189.354
195.034
198.821
202.608
488
M-1-50-ii
381.173
392.608
400.232
407.855
489
M-1-50-iii
583.522
601.028
612.698
624.369
142.902
147.189
150.047
152.905
286.091
294.674
300.396
306.117
497.900
512.837
522.795
532.753
191.431
197.174
201.003
204.832
390.615
402.333
410.146
417.958
629.718
648.610
661.204
673.799

RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
SELAIN KAKI (BERAT)
490
M-1-60-i
491
M-1-60-ii
492
M-1-60-iii
493
M-1-70-i
494
M-1-70-ii
495
M-1-70-iii
496
M-1-80-i
154.242
158.869
161.954
165.039
497
M-1-80-ii
233.182
240.178
244.841
249.505
498
M-1-80-iii
536.846
552.951
563.688
574.425
499
M-4-10-i
108.293
111.542
113.708
115.874
500
M-4-10-ii
162.440
167.313
170.562
173.811
501
M-4-10-iii
FRAKTUR FEMUR BERAT
316.479
325.973
332.303
338.632
- 503 No
Kode
INA-CBG
502
M-4-11-i
503
M-4-11-ii
504
M-4-11-iii
505
M-4-12-i
506
M-4-12-ii
507
M-4-12-iii
508
M-4-13-i
509
M-4-13-ii
510
M-4-13-iii
511
M-4-14-i
512
Deskripsi (INA-CBG)
PANGGUL RINGAN
PANGGUL SEDANG
PANGGUL BERAT
PELVIS RINGAN
PELVIS SEDANG
PELVIS BERAT
KONEKTIF DAN FRAKTUR PATOLOGIS
RINGAN
SEDANG
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
135.367
139.428
142.135
144.842
296.585
305.482
311.414
317.346
526.431
542.224
552.753
563.281
108.293
111.542
113.708
115.874
197.040
202.951
206.892
210.832
355.956
366.634
373.753
380.873
180.332
185.742
189.348
192.955
270.733
278.855
284.270
289.685
536.442
552.535
563.264
573.993
205.317
211.477
215.583
219.689
M-4-14-ii
253.638
261.247
266.320
271.393
513
M-4-14-iii
OSTEOMIELITIS BERAT
379.922
391.320
398.919
406.517
514
M-4-15-i
121.888
125.544
127.982
130.420
515
M-4-15-ii
162.527
167.403
170.654
173.904
516
M-4-15-iii
460.247
474.054
483.259
492.464
517
M-4-16-i
135.367
139.428
142.135
144.842
518
M-4-16-ii
216.587
223.084
227.416
231.748
519
M-4-16-iii
363.270
374.168
381.433
388.699
520
M-4-17-i
135.367
139.428
142.135
144.842
521
M-4-17-ii
189.513
195.199
198.989
202.779
522
M-4-17-iii
264.665
272.605
277.899
283.192
523
M-4-18-i
143.125
147.419
150.281
153.144
524
M-4-18-ii
216.587
223.084
227.416
231.748
525
M-4-18-iii
242.731
250.013
254.868
259.723
526
M-4-19-i
106.415
109.608
111.736
113.864
527
M-4-19-ii
179.237
184.615
188.199
191.784
528
M-4-19-iii
350.064
360.566
367.567
374.568
529
M-4-20-i
108.293
111.542
113.708
115.874
530
M-4-20-ii
162.440
167.313
170.562
173.811

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
RINGAN
SEDANG
BERAT
MALFUNGSI, REAKSI ATAU KOMPLIKASI
DARI PROSEDUR ATAU PEMASANGAN ALAT
ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
TANDA-TANDA, GEJALA, MUSKULOSKLETAL
, KESELEO DAN PERADANGAN MINOR
(RINGAN)
TANDA-TANDA, GEJALA,
MUSKULOSKLETAL, KESELEO DAN
PERADANGAN MINOR (SEDANG)
- 504 No
Kode
INA-CBG
531
M-4-20-iii
532
M-4-21-i
533
M-4-21-ii
534
M-4-21-iii
535
N-1-01-i
536
N-1-01-ii
537
N-1-01-iii
538
N-1-11-i
539
N-1-11-ii
540
N-1-11-iii
541
N-1-12-i
542
N-1-12-ii
543
N-1-12-iii
544
N-1-20-i
545
N-1-20-ii
546
N-1-20-iii
Deskripsi (INA-CBG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
PROSEDUR PENCANGKOKAN GINJAL
RINGAN
SEDANG
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
180.022
185.422
189.023
192.623
108.293
111.542
113.708
115.874
135.367
139.428
142.135
144.842
310.794
320.118
326.334
332.550
4.147.845
4.272.281
4.355.237
4.438.194
5.609.867
5.778.163
5.890.360
6.002.558
11.894.587
12.251.424
12.489.316
12.727.208
5.722.273
5.893.941
6.008.386
6.122.832
7.739.245
7.971.422
8.126.207
8.280.992
16.409.501
16.901.786
17.229.976
17.558.166
3.097.599
3.190.527
3.252.479
3.314.431
7.206.344
7.422.534
7.566.661
7.710.788
13.134.011
13.528.031
13.790.712
14.053.392
4.193.904
4.319.721
4.403.599
4.487.477
8.315.021
8.564.471
8.730.772
8.897.072
9.511.630
9.796.979
9.987.211
10.177.444
4.989.389
5.139.071
5.238.858
5.338.646
7.581.999
7.809.459
7.961.099
8.112.739
8.728.131
8.989.975
9.164.538
9.339.100
4.495.928
4.630.806
4.720.724
4.810.643
6.094.391
6.277.222
6.399.110
6.520.998
7.087.952
7.300.591
7.442.350
7.584.109
1.916.232
1.973.719
2.012.044
2.050.369
2.565.889
2.642.865
2.694.183
2.745.501
5.616.269
5.784.757
5.897.082
6.009.407

RINGAN
SEDANG
BERAT

URIN BAWAH RINGAN
URIN BAWAH SEDANG
URIN BAWAH BERAT
PROSEDUR PADA URETRA DAN
TRANSURETRA RINGAN
TRANSURETRA SEDANG
TRANSURETRA BERAT
GINJAL RINGAN
GINJAL SEDANG
GINJAL BERAT
547
N-1-30-i
548
N-1-30-ii
549
N-1-30-iii
550
N-1-40-i
551
N-1-40-ii
552
N-1-40-iii
553
N-4-10-i
554
N-4-10-ii
555
N-4-10-iii
556
N-4-11-i
1.467.457
1.511.480
1.540.830
1.570.179
557
N-4-11-ii
2.479.967
2.554.366
2.603.965
2.653.564
558
N-4-11-iii
2.874.349
2.960.579
3.018.066
3.075.553
559
N-4-12-i
1.532.986
1.578.975
1.609.635
1.640.295
560
N-4-12-ii
2.299.479
2.368.463
2.414.453
2.460.442
INFEKSI GINJAL DAN SALURAN URIN

RINGAN
SEDANG
No
Kode
INA-CBG
561
N-4-12-iii
3.817.891
3.932.427
4.008.785
4.085.143
562
N-4-13-i
BATU URIN RINGAN
2.022.480
2.083.154
2.123.604
2.164.053
563
N-4-13-ii
BATU URIN SEDANG
2.438.350
2.511.500
2.560.267
2.609.034
564
N-4-13-iii
BATU URIN BERAT
6.004.987
6.185.137
6.305.236
6.425.336
1.327.850
1.367.685
1.394.242
1.420.799
2.044.722
2.106.064
2.146.958
2.187.852
3.315.887
3.415.364
3.481.681
3.547.999
1.969.969
2.029.068
2.068.467
2.107.867
2.703.410
2.784.513
2.838.581
2.892.649
3.085.079
3.177.631
3.239.333
3.301.035
2.556.747
2.633.450
2.684.585
2.735.720
3.065.972
3.157.951
3.219.270
3.280.590
6.447.283
6.640.701
6.769.647
6.898.592
3.775.164
3.888.419
3.963.922
4.039.425
4.191.007
4.316.737
4.400.558
4.484.378
4.698.169
4.839.114
4.933.078
5.027.041
1.973.036
2.032.227
2.071.687
2.111.148
2.531.225
2.607.161
2.657.786
2.708.410
4.289.640
4.418.329
4.504.122
4.589.915
1.718.129
1.769.672
1.804.035
1.838.398
2.063.468
2.125.372
2.166.642
2.207.911
2.592.452
2.670.226
2.722.075
2.773.924
Deskripsi (INA-CBG)

DARI PEMASANGAN ALAT SALURAN URIN,
(RINGAN)
(SEDANG)
(BERAT)
SALURAN URIN RINGAN
SALURAN URIN SEDANG
SALURAN URIN BERAT
DIAGNOSIS GINJAL DAN SALURAN URIN
LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
RINGAN
SEDANG
BERAT
&KURET RINGAN
& KURET SEDANG
& KURET BERAT
Regional 1
Regional 2
Regional 3
Regional 4
565
N-4-14-i
566
N-4-14-ii
567
N-4-14-iii
568
N-4-15-i
569
N-4-15-ii
570
N-4-15-iii
571
N-4-16-i
572
N-4-16-ii
573
N-4-16-iii
574
O-6-10-i
575
O-6-10-ii
576
O-6-10-iii
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
1.721.875
1.773.531
1.807.968
1.842.406
584
O-6-13-ii
2.537.705
2.613.836
2.664.590
2.715.345
585
O-6-13-iii
2.999.176
3.089.151
3.149.135
3.209.118
38.517.557
39.673.083
40.443.434
41.213.786
47.659.451
49.089.235
50.042.424
50.995.613
586
P-8-01-i
587
P-8-01-ii

- 506 No
Kode
INA-CBG
588
P-8-01-iii
589
P-8-02-i
590
P-8-02-ii
591
P-8-02-iii
592
P-8-03-i
593
P-8-03-ii
594
P-8-03-iii
595
P-8-04-i
596
P-8-04-ii
597
P-8-04-iii
598
P-8-05-i
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii
603
P-8-06-iii
604
P-8-07-i
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
Deskripsi (INA-CBG)
GROUP-1 DENGAN PROSEDUR MAYOR
RINGAN
SEDANG
RINGAN
SEDANG
RINGAN
SEDANG
RINGAN
SEDANG
RINGAN
SEDANG
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
KE FASILITAS PERAWATAN PASIEN AKUT
LAIN RINGAN
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
55.938.835
57.617.001
58.735.777
59.854.554
46.667.026
48.067.037
49.000.377
49.933.718
53.531.882
55.137.839
56.208.476
57.279.114
61.164.003
62.998.923
64.222.203
65.445.483
2.581.332
2.658.772
2.710.399
2.762.025
3.613.865
3.722.281
3.794.558
3.866.836
5.692.657
5.863.437
5.977.290
6.091.143
23.053.110
23.744.703
24.205.765
24.666.828
29.917.966
30.815.505
31.413.865
32.012.224
42.894.833
44.181.678
45.039.575
45.897.471
12.535.534
12.911.600
13.162.310
13.413.021
17.767.429
18.300.452
18.655.801
19.011.149
26.177.922
26.963.259
27.486.818
28.010.376
2.065.066
2.127.018
2.168.319
2.209.620
5.196.247
5.352.134
5.456.059
5.559.984
9.665.611
9.955.580
10.148.892
10.342.204
3.613.865
3.722.281
3.794.558
3.866.836
10.132.408
10.436.380
10.639.028
10.841.676
13.422.928
13.825.615
14.094.074
14.362.533
2.618.902
2.697.469
2.749.847
2.802.225
3.717.900
3.829.437
3.903.795
3.978.153
5.248.533
5.405.989
5.510.960
5.615.931
1.624.764
1.673.507
1.706.002
1.738.497
- 507 No
Kode
INA-CBG
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
614
P-8-11-ii
615
P-8-11-iii
616
P-8-12-i
617
P-8-12-ii
618
P-8-12-iii
619
P-8-13-i
620
P-8-13-ii
621
P-8-13-iii
622
P-8-14-i
623
P-8-14-ii
624
P-8-14-iii
625
P-8-15-i
626
P-8-15-ii
627
P-8-15-iii
628
P-8-16-i
629
P-8-16-ii
630
P-8-16-iii
631
P-8-17-i
632
P-8-17-ii
633
P-8-17-iii
634
S-4-10-i
635
S-4-10-ii
636
S-4-10-iii
637
S-4-11-i
638
639
Deskripsi (INA-CBG)
LAIN SEDANG
LAIN BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
ANOMALI MAYOR ATAU KONDISI
HEREDITER RINGAN
HEREDITER SEDANG
HEREDITER BERAT
SINDROMA ASPIRASI RINGAN
SINDROMA ASPIRASI SEDANG
SINDROMA ASPIRASI BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.353.707
2.424.318
2.471.392
2.518.467
4.621.021
4.759.651
4.852.072
4.944.492
4.576.026
4.713.307
4.804.827
4.896.348
9.742.233
10.034.500
10.229.345
10.424.190
9.946.335
10.244.725
10.443.652
10.642.578
2.158.849
2.223.614
2.266.791
2.309.968
3.356.635
3.457.334
3.524.467
3.591.600
3.960.120
4.078.923
4.158.126
4.237.328
1.115.809
1.149.284
1.171.600
1.193.916
2.064.797
2.126.741
2.168.037
2.209.332
3.088.124
3.180.768
3.242.530
3.304.293
2.038.700
2.099.861
2.140.635
2.181.409
4.162.448
4.287.322
4.370.571
4.453.820
4.566.190
4.703.176
4.794.500
4.885.824
1.533.166
1.579.161
1.609.824
1.640.488
3.064.396
3.156.327
3.217.615
3.278.903
3.599.607
3.707.595
3.779.587
3.851.580
1.387.878
1.429.514
1.457.271
1.485.029
1.968.764
2.027.826
2.067.202
2.106.577
2.555.552
2.632.218
2.683.329
2.734.441
915.996
943.476
961.796
980.116
3.042.629
3.133.908
3.194.761
3.255.613
6.141.353
6.325.594
6.448.421
6.571.248
1.532.986
1.578.975
1.609.635
1.640.295
1.916.232
1.973.719
2.012.044
2.050.369
2.490.773
2.565.496
2.615.312
2.665.127
958.116
986.860
1.006.022
1.025.184
S-4-11-ii
1.458.271
1.502.019
1.531.184
1.560.350
S-4-11-iii
2.359.227
2.430.004
2.477.189
2.524.373
- 508 No
Kode
INA-CBG
640
S-4-12-i
641
S-4-12-ii
642
S-4-12-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
PASIEN RINGAN
PASIEN SEDANG
PASIEN BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.149.739
1.184.232
1.207.226
1.230.221
1.532.986
1.578.975
1.609.635
1.640.295
2.994.043
3.083.864
3.143.745
3.203.626
1.532.986
1.578.975
1.609.635
1.640.295
2.709.975
2.791.275
2.845.474
2.899.674
5.517.854
5.683.390
5.793.747
5.904.104
934.020
962.041
980.721
999.402
1.984.172
2.043.697
2.083.381
2.123.064
3.762.697
3.875.578
3.950.832
4.026.086
706.408
727.600
741.728
755.857
1.333.233
1.373.230
1.399.894
1.426.559
1.726.846
1.778.651
1.813.188
1.847.725
643
S-4-13-i
644
S-4-13-ii
645
S-4-13-iii
646
S-4-14-i
647
S-4-14-ii
648
S-4-14-iii
649
S-4-15-i
650
S-4-15-ii
651
S-4-15-iii
652
S-4-16-i
LUKA BAKAR RINGAN
2.682.725
2.763.207
2.816.862
2.870.516
653
S-4-16-ii
LUKA BAKAR SEDANG
3.788.882
3.902.549
3.978.326
4.054.104
654
S-4-16-iii
LUKA BAKAR BERAT
6.765.637
6.968.606
7.103.919
7.239.232
1.430.482
1.473.396
1.502.006
1.530.615
1.916.232
1.973.719
2.012.044
2.050.369
3.124.795
3.218.539
3.281.035
3.343.531
1.476.652
1.520.952
1.550.485
1.580.018
1.983.043
2.042.535
2.082.196
2.121.856
3.607.802
3.716.036
3.788.193
3.860.349
645.930
665.308
678.226
691.145
1.230.999
1.267.929
1.292.549
1.317.169
1.789.538
1.843.224
1.879.015
1.914.806
638.787
657.951
670.727
683.503
1.005.270
1.035.428
1.055.533
1.075.639
1.619.193
1.667.769
1.700.153
1.732.537
1.341.363
1.381.604
1.408.431
1.435.258
2.027.396
2.088.218
2.128.766
2.169.314
3.153.899
3.248.516
3.311.594
3.374.672
655
S-4-17-i
656
S-4-17-ii
657
S-4-17-iii
658
T-1-10-i
659
T-1-10-ii
660
T-1-10-iii
661
T-4-10-i
662
T-4-10-ii
663
T-4-10-iii
664
T-4-11-i
665
T-4-11-ii
666
T-4-11-iii
667
T-4-12-i
668
T-4-12-ii
669
T-4-12-iii
DIAGNOSIS KECEDERAAN, KERACUNAN

DAN EFEK TOKSIK LAIN-LAIN RINGAN
DAN EFEK TOKSIK LAIN-LAIN SEDANG
DAN EFEK TOKSIK LAIN-LAIN BERAT
DOKTER RINGAN
DOKTER SEDANG
DOKTER BERAT
No
Kode
INA-CBG
670
U-1-10-i
1.427.758
1.470.590
1.499.146
1.527.701
671
U-1-10-ii
2.913.427
3.000.830
3.059.099
3.117.367
672
U-1-10-iii
12.580.768
12.958.191
13.209.806
13.461.421
673
U-1-11-i
6.195.197
6.381.053
6.504.957
6.628.861
674
U-1-11-ii
8.260.263
8.508.071
8.673.276
8.838.482
675
U-1-11-iii
13.877.977
14.294.317
14.571.876
14.849.436
676
U-1-12-i
3.785.952
3.899.531
3.975.250
4.050.969
677
U-1-12-ii
9.292.796
9.571.580
9.757.436
9.943.292
678
U-1-12-iii
12.066.872
12.428.878
12.670.215
12.911.553
679
U-1-13-i
4.130.132
4.254.036
4.336.638
4.419.241
680
U-1-13-ii
4.659.909
4.799.706
4.892.904
4.986.103
681
U-1-13-iii
8.985.619
9.255.187
9.434.900
9.614.612
682
U-1-14-i
2.278.877
2.347.243
2.392.821
2.438.398
683
U-1-14-ii
2.796.640
2.880.539
2.936.472
2.992.405
684
U-1-14-iii
3.314.097
3.413.520
3.479.802
3.546.084
685
U-1-15-i
1.338.471
1.378.625
1.405.395
1.432.164
686
U-1-15-ii
1.901.874
1.958.930
1.996.968
2.035.005
687
U-1-15-iii
3.747.719
3.860.151
3.935.105
4.010.060
688
U-1-20-i
3.462.042
3.565.903
3.635.144
3.704.385
689
U-1-20-ii
6.162.435
6.347.308
6.470.557
6.593.805
690
U-1-20-iii
15.202.952
15.659.040
15.963.099
16.267.158
691
U-1-30-i
2.969.828
3.058.923
3.118.320
3.177.716
692
U-1-30-ii
4.009.268
4.129.546
4.209.732
4.289.917
693
U-1-30-iii
7.859.319
8.095.098
8.252.284
8.409.471
694
U-4-10-i
2.764.414
2.847.347
2.902.635
2.957.923
695
U-4-10-ii
6.929.806
7.137.700
7.276.296
7.414.892
696
U-4-10-iii
10.109.077
10.412.350
10.614.531
10.816.713
697
U-4-11-i
1.532.986
1.578.975
1.609.635
1.640.295
698
U-4-11-ii
2.299.479
2.368.463
2.414.453
2.460.442
699
U-4-11-iii
3.180.170
3.275.575
3.339.179
3.402.782
700
U-4-12-i
1.532.986
1.578.975
1.609.635
1.640.295
701
U-4-12-ii
1.787.108
1.840.722
1.876.464
1.912.206
702
U-4-12-iii
2.841.421
2.926.664
2.983.492
3.040.321
Deskripsi (INA-CBG)

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
PROSEDUR OPERASI BIBIR SUMBING &

LANGIT-LANGIT MULUT (RINGAN)
LANGIT-LANGIT MULUT (SEDANG)
LANGIT-LANGIT MULUT (BERAT)
PROSEDUR TENGGOROKAN, MULUT,

HIDUNG DAN TELINGA LAIN-LAIN (RINGAN)
HIDUNG DAN TELINGA LAIN-LAIN (SEDANG)
HIDUNG DAN TELINGA LAIN-LAIN (BERAT)

DAN TELINGA RINGAN
DAN TELINGA SEDANG
DAN TELINGA BERAT
Regional 1
Regional 2
Regional 3
Regional 4
- 510 No
Kode
INA-CBG
703
U-4-13-i
704
U-4-13-ii
705
U-4-13-iii
706
U-4-14-i
707
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.506.046
1.551.227
1.581.348
1.611.469
1.750.866
1.803.392
1.838.409
1.873.427
1.987.980
2.047.620
2.087.379
2.127.139
1.916.232
1.973.719
2.012.044
2.050.369
U-4-14-ii
2.299.479
2.368.463
2.414.453
2.460.442
708
U-4-14-iii
3.852.026
3.967.587
4.044.627
4.121.668
709
U-4-15-i
1.532.986
1.578.975
1.609.635
1.640.295
710
U-4-15-ii
1.916.232
1.973.719
2.012.044
2.050.369
711
U-4-15-iii
2.683.245
2.763.743
2.817.408
2.871.073
712
V-1-10-i
4.481.426
4.615.869
4.705.497
4.795.126
713
V-1-10-ii
5.162.664
5.317.544
5.420.798
5.524.051
714
V-1-10-iii
9.809.062
10.103.334
10.299.516
10.495.697
715
V-1-11-i
5.162.664
5.317.544
5.420.798
5.524.051
716
V-1-11-ii
5.761.620
5.934.469
6.049.701
6.164.934
717
V-1-11-iii
8.532.077
8.788.040
8.958.681
9.129.323
2.788.254
2.871.902
2.927.667
2.983.432
10.655.780
10.975.453
11.188.569
11.401.685
12.441.594
12.814.842
13.063.674
13.312.506
4.226.089
4.352.872
4.437.394
4.521.916
8.030.782
8.271.706
8.432.321
8.592.937
12.390.395
12.762.107
13.009.914
13.257.722
5.094.600
5.247.438
5.349.330
5.451.222
7.409.659
7.631.949
7.780.142
7.928.335
10.072.353
10.374.524
10.575.971
10.777.418
DIAGNOSIS TENGGOROKAN, MULUT,

HIDUNG & TELINGA LAIN-LAIN (RINGAN)
HIDUNG & TELINGA LAIN-LAIN (SEDANG)
HIDUNG & TELINGA LAIN-LAIN (BERAT)
KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

NON KOMPLEK (BERAT)
718
V-1-12-i
719
V-1-12-ii
720
V-1-12-iii
721
V-1-13-i
722
V-1-13-ii
723
V-1-13-iii
724
V-1-14-i
725
V-1-14-ii
726
V-1-14-iii
727
V-1-15-i
2.401.820
2.473.875
2.521.911
2.569.948
728
V-1-15-ii
4.575.000
4.712.250
4.803.750
4.895.250
729
V-1-15-iii
8.042.762
8.284.045
8.444.900
8.605.756
730
V-4-10-i
3.867.537
3.983.563
4.060.914
4.138.264
731
V-4-10-ii
4.995.386
5.145.247
5.245.155
5.345.063
732
V-4-10-iii
9.547.059
9.833.470
10.024.412
10.215.353
733
V-4-11-i
1.966.787
2.025.791
2.065.127
2.104.462
734
V-4-11-ii
2.873.790
2.960.004
3.017.480
3.074.956
TUMOR PADA SISTEM REPRODUKSI LAKILAKI RINGAN

TUMOR PADA SISTEM REPRODUKSI LAKILAKI SEDANG
TUMOR PADA SISTEM REPRODUKSI LAKILAKI BERAT
- 511 No
Kode
INA-CBG
735
V-4-11-iii
736
W-1-01-i
737
W-1-01-ii
738
W-1-01-iii
739
W-1-10-i
740
W-1-10-ii
741
W-1-10-iii
742
W-1-11-i
743
W-1-11-ii
744
W-1-11-iii
745
W-1-12-i
746
W-1-12-ii
747
W-1-12-iii
748
W-1-13-i
749
W-1-13-ii
750
W-1-13-iii
751
W-1-20-i
752
W-1-20-ii
753
W-1-20-iii
754
W-1-30-i
755
W-1-30-ii
756
W-1-30-iii
757
W-4-10-i
758
W-4-10-ii
759
W-4-10-iii
760
W-4-11-i
761
W-4-11-ii
762
W-4-11-iii
763
W-4-12-i
764
W-4-12-ii
Deskripsi (INA-CBG)
PROSEDUR OPERASI PENGANGKATAN
RAHIM DAN VULVA RADIKAL & EVISCERASI
RINGAN
SEDANG
BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.741.564
4.883.811
4.978.642
5.073.473
5.783.318
5.956.817
6.072.484
6.188.150
6.965.732
7.174.704
7.314.018
7.453.333
15.385.918
15.847.495
16.155.214
16.462.932
1.610.647
1.658.966
1.691.179
1.723.392
3.005.732
3.095.904
3.156.018
3.216.133
4.916.423
5.063.916
5.162.244
5.260.573
1.672.927
1.723.114
1.756.573
1.790.031
3.226.451
3.323.244
3.387.773
3.452.302
6.195.197
6.381.053
6.504.957
6.628.861
1.520.105
1.565.708
1.596.111
1.626.513
1.728.331
1.780.180
1.814.747
1.849.314
2.654.934
2.734.582
2.787.680
2.840.779
1.809.285
1.863.563
1.899.749
1.935.934
1.964.362
2.023.292
2.062.580
2.101.867
2.638.500
2.717.655
2.770.425
2.823.195
4.929.785
5.077.678
5.176.274
5.274.870
6.934.482
7.142.517
7.281.206
7.419.896
8.760.206
9.023.012
9.198.216
9.373.420
2.691.168
2.771.903
2.825.727
2.879.550
PROSEDUR DILATASI, KURET, INTRAUTERIN

& SERVIK RINGAN
& SERVIK SEDANG
& SERVIK BERAT
ENDOSKOP RINGAN
ENDOSKOP SEDANG
ENDOSKOP BERAT
PROSEDUR PADA RAHIM & ADNEKSA
RINGAN
SEDANG
RINGAN
SEDANG
BERAT
TUMOR SISTEM REPRODUKSI WANITA
RINGAN
SEDANG
4.292.553
4.421.329
4.507.180
4.593.031
11.414.953
11.757.402
11.985.701
12.214.000
2.006.937
2.067.145
2.107.284
2.147.423
2.712.601
2.793.979
2.848.231
2.902.483
6.131.944
6.315.902
6.438.541
6.561.180
1.916.232
1.973.719
2.012.044
2.050.369
3.065.972
3.157.951
3.219.270
3.280.590
3.726.064
3.837.846
3.912.368
3.986.889
1.532.986
1.578.975
1.609.635
1.640.295
2.107.856
2.171.091
2.213.248
2.255.406
INFEKSI SISTEM REPRODUKSI WANITA

RINGAN
SEDANG
- 512 No
Kode
INA-CBG
765
W-4-12-iii

766
W-4-13-i
767
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.350.025
2.420.526
2.467.526
2.514.527
ABORTUS RINGAN
840.708
865.929
882.743
899.557
W-4-13-ii
ABORTUS SEDANG
1.149.739
1.184.232
1.207.226
1.230.221
768
W-4-13-iii
ABORTUS BERAT
1.532.986
1.578.975
1.609.635
1.640.295
769
W-4-14-i
1.149.739
1.184.232
1.207.226
1.230.221
770
W-4-14-ii
1.478.751
1.523.113
1.552.688
1.582.263
771
W-4-14-iii
1.860.721
1.916.542
1.953.757
1.990.971
772
W-4-15-i
958.749
987.511
1.006.686
1.025.861
773
W-4-15-ii
1.066.311
1.098.301
1.119.627
1.140.953
774
W-4-15-iii
1.476.409
1.520.702
1.550.230
1.579.758
775
W-4-16-i
1.149.739
1.184.232
1.207.226
1.230.221
776
W-4-16-ii
1.532.986
1.578.975
1.609.635
1.640.295
777
W-4-16-iii
2.090.018
2.152.718
2.194.519
2.236.319
778
W-4-17-i
939.056
967.228
986.009
1.004.790
779
W-4-17-ii
1.532.986
1.578.975
1.609.635
1.640.295
780
W-4-17-iii
2.900.104
2.987.108
3.045.110
3.103.112
781
Z-4-10-i
REHABILITASI RINGAN
2.630.422
2.709.335
2.761.943
2.814.552
782
Z-4-10-ii
REHABILITASI SEDANG
3.491.506
3.596.251
3.666.081
3.735.911
783
Z-4-10-iii
REHABILITASI BERAT
4.960.017
5.108.818
5.208.018
5.307.218
784
Z-4-11-i
2.296.069
2.364.951
2.410.873
2.456.794
785
Z-4-11-ii
2.763.960
2.846.879
2.902.158
2.957.437
786
Z-4-11-iii
4.373.076
4.504.268
4.591.730
4.679.191
787
Z-4-12-i
1.149.739
1.184.232
1.207.226
1.230.221
788
Z-4-12-ii
2.342.556
2.412.833
2.459.684
2.506.535
789
Z-4-12-iii
2.977.018
3.066.329
3.125.869
3.185.409
GEJALA-GEJALA DAN TANDA-TANDA

RINGAN
SEDANG
- 513 b. RawatJalan
No
Kode
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
775.006
798.256
813.756
829.256
1.005.304
1.035.463
1.055.569
1.075.675
1.869.494
1.925.579
1.962.969
2.000.359
1.544.956
1.591.304
1.622.204
1.653.103
1.290.677
1.329.398
1.355.211
1.381.025
452.517
466.093
475.143
484.193
1.009.054
1.039.326
1.059.507
1.079.688

207.327
213.547
217.694
221.840
C-3-10-0
565.560
582.527
593.838
605.149
10
C-3-11-0

KANDUNG KEMIH
894.454
921.288
939.177
957.066
11
C-3-12-0
202.771
208.854
212.909
216.965
196.904
202.812
206.750
210.688
1.676.251
1.726.538
1.760.063
1.793.588
1.536.351
1.582.441
1.613.168
1.643.895

LAPAROSKOPI
& PANKREAS
LAPAROSKOPI
SALURAN EMPEDU
KEMOTERAPI PADA TUMOR PAYUDARA

ATAU OVARIUM
GASTROINTESTINAL
GINJAL ATAU PROSTAT
12
C-3-13-0
13
C-3-14-0
14
C-3-15-0
15
C-3-16-0
348.407
358.860
365.828
372.796
16
C-3-17-0

LEHER
231.123
238.057
242.679
247.302
17
C-3-18-0
102.470
105.544
107.594
109.643
18
C-3-19-0

MYELOMA ATAU TESTIS
144.913
149.261
152.159
155.057
19
C-3-20-0
2.885.957
2.972.536
3.030.255
3.087.974
20
C-3-21-0
165.372
170.333
173.641
176.948
21
C-3-22-0
726.072
747.854
762.376
776.897
22
C-3-23-0
117.608
121.136
123.488
125.840
23
D-2-10-0

TULANG
996.390
1.026.282
1.046.209
1.066.137
24
D-2-11-0
PROSEDUR LIMPA
1.247.650
1.285.080
1.310.033
1.334.986
25
D-2-21-0
1.046.425
1.077.818
1.098.747
1.119.675
26
D-2-22-0
229.659
236.549
241.142
245.735
27
D-3-10-0
166.348
171.338
174.665
177.992
28
D-3-11-0
431.886
444.843
453.481
462.118
29
E-2-10-0
256.192
263.877
269.001
274.125
30
E-2-21-0
185.730
191.302
195.017
198.731
31
E-2-22-0
185.730
191.302
195.017
198.731

TYMUS
TYMUS
TULANG
PEMBENTUK DARAH
DAN PARATIROID
THYROGLOSSAL
No
Kode
INA-CBG
32
E-3-10-0

ENDOKRIN
215.992
33
F-3-10-0
TERAPI SHOCK
34
F-5-10-0
PELAYANAN KESEHATAN MENTAL

EKSTENSIF
35
F-5-11-0
36
Deskripsi (INA-CBG)
Regional 3
Regional 4
222.472
226.792
231.112
301.302
310.341
316.367
322.393
369.193
380.268
387.652
395.036
TERAPI KELOMPOK
243.449
250.752
255.621
260.490
F-5-12-0
PROSEDUR TES DIAGNOSTIK KESEHATAN

JIWA
311.534
320.880
327.110
333.341
37
F-5-13-0
263.848
271.764
277.041
282.318
38
F-5-14-0
177.007
182.317
185.857
189.397
39
F-5-15-0
166.055
171.037
174.358
177.679
40
F-5-16-0
172.963
178.151
181.611
185.070
41
G-2-10-0
145.648
150.017
152.930
155.843
42
G-2-11-0
1.262.536
1.300.412
1.325.663
1.350.914
43
G-2-12-0

EKSTRAKRANIAL
1.829.726
1.884.618
1.921.212
1.957.807
44
G-2-13-0
448.873
462.339
471.316
480.294
45
G-2-21-0
818.668
843.228
859.601
875.975
46
G-2-22-0
743.011
765.301
780.161
795.022
47
G-2-31-0
1.226.033
1.262.814
1.287.334
1.311.855
48
G-2-32-0
628.463
647.317
659.886
672.456
49
G-3-10-0
249.441
256.924
261.913
266.902
50
G-3-11-0
332.208
342.174
348.818
355.462
51
G-3-12-0
544.328
560.658
571.544
582.431
52
G-3-13-0
544.390
560.722
571.610
582.497
53
H-2-21-0
714.431
735.864
750.153
764.441
54
H-2-22-0
185.730
191.302
195.017
198.731
55
H-2-23-0
185.730
191.302
195.017
198.731
56
H-2-31-0
1.183.396
1.218.898
1.242.565
1.266.233
57
H-2-32-0
123.164
126.859
129.322
131.785
58
H-2-33-0
185.730
191.302
195.017
198.731
59
H-2-34-0
530.900
546.827
557.445
568.063
60
H-2-35-0
174.944
180.192
183.691
187.190
61
H-2-36-0
944.305
972.634
991.520
1.010.406
62
H-2-37-0

1.005.254
1.035.412
1.055.517
1.075.622
63
H-3-10-0
349.755
360.248
367.243
374.238
64
H-3-11-0
183.932
189.450
193.129
196.808

AKUT
PENGOBATAN INDIVIDU
KETERBELAKANGAN MENTAL
PROSEDUR KRANIOTOMI

MATA
PROSEDUR SEDANG PADA SEGMEN
ANTERIOR MATA
MATA
MATA
MATA
Regional 1
Regional 2
- 515 No
Kode
INA-CBG
65
H-3-12-0
66
H-3-13-0
67
I-2-11-0
68
I-2-12-0
69
I-2-13-0
70
I-2-14-0
71
I-2-15-0
Deskripsi (INA-CBG)
MATA
TORASIK
ABDOMEN
PENGGANTIAN ALAT
PEMBULUH DARAH VENA
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
192.035
197.796
201.636
205.477
186.454
192.048
195.777
199.506
2.150.214
2.214.720
2.257.725
2.300.729
1.511.835
1.557.190
1.587.427
1.617.663
1.921.451
1.979.095
2.017.524
2.055.953
3.400.560
3.502.576
3.570.588
3.638.599
204.503
210.638
214.728
218.818
2.147.884
2.212.320
2.255.278
2.298.235
708.096
729.338
743.500
757.662
72
I-2-16-0
73
I-2-17-0
74
I-2-21-0
1.657.861
1.707.597
1.740.754
1.773.911
75
I-2-22-0
PROSEDUR SEDANG PADA PEMBULUH

DARAH
1.561.166
1.608.001
1.639.225
1.670.448
76
I-2-23-0
319.488
329.073
335.462
341.852
2.484.766
2.559.309
2.609.004
2.658.700
3.249.197
3.346.672
3.411.656
3.476.640

PACU JANTUNG
77
I-2-31-0
78
I-2-32-0
79
I-2-41-0
2.178.626
2.243.985
2.287.558
2.331.130
80
I-2-42-0

KORONER DAN KARDIOVASKULAR
PERKUTAN LAIN
2.533.013
2.609.004
2.659.664
2.710.324
81
I-3-10-0
PROSEDUR RESUSITASI
321.544
331.190
337.621
344.052
82
I-3-11-0
169.710
174.801
178.195
181.590
83
I-3-12-0
986.290
1.015.879
1.035.605
1.055.331
84
I-3-13-0
323.936
333.654
340.133
346.611
85
I-3-14-0
207.632
213.861
218.013
222.166
86
I-3-15-0
183.932
189.450
193.129
196.808
87
J-2-10-0
1.138.791
1.172.955
1.195.730
1.218.506
88
J-2-21-0
183.573
189.080
192.752
196.423
89
J-2-22-0
925.093
952.845
971.347
989.849
90
J-2-31-0
PROSEDUR
1.199.928
1.235.926
1.259.924
1.283.923
91
J-2-32-0
892.945
919.734
937.593
955.452
92
J-3-10-0
185.730
191.302
195.017
198.731
93
J-3-11-0

PADA DADA
524.840
540.586
551.082
561.579
94
J-3-12-0
202.771
208.854
212.909
216.965
95
J-3-13-0
298.428
307.381
313.350
319.318
96
J-3-14-0
316.814
326.318
332.655
338.991

KARDIOVASKULAR
PERNAFASAN
PENDEK
No
Kode
INA-CBG
97
J-3-15-0
277.821
98
J-3-16-0
99
J-3-17-0
100
K-2-10-0
101
K-2-11-0
102
K-2-12-0
103
K-2-13-0
104
K-2-14-0
105
K-2-21-0
106
K-2-22-0
107
K-2-31-0
108
K-2-32-0
109
K-2-41-0
110
Deskripsi (INA-CBG)
Regional 3
Regional 4
286.155
291.712
297.268
316.814
326.318
332.655
338.991
185.730
191.302
195.017
198.731
534.595
550.633
561.325
572.017
1.141.578
1.175.826
1.198.657
1.221.489
876.309
902.598
920.124
937.650
1.426.240
1.469.027
1.497.552
1.526.077
185.730
191.302
195.017
198.731
185.730
191.302
195.017
198.731
2.387.075
2.458.687
2.506.429
2.554.170
802.652
826.732
842.785
858.838
185.730
191.302
195.017
198.731
884.138
910.662
928.345
946.027
K-2-42-0

252.609
260.187
265.240
270.292
111
K-2-51-0
585.883
603.460
615.177
626.895
112
K-2-52-0
319.488
329.073
335.462
341.852
113
K-2-53-0
185.730
191.302
195.017
198.731
114
K-3-10-0

GASTROINTESTINAL
353.432
364.035
371.104
378.172
115
K-3-11-0
212.482
218.856
223.106
227.355
116
K-3-12-0
215.483
221.948
226.257
230.567
117
K-3-13-0
185.730
191.302
195.017
198.731
118
K-3-14-0
497.761
512.694
522.649
532.604
119
K-3-15-0
240.376
247.587
252.394
257.202
120
K-3-16-0
318.513
328.068
334.439
340.809
121
L-2-21-0
1.095.060
1.127.911
1.149.813
1.171.714
122
L-2-22-0
701.925
722.983
737.022
751.060
123
L-2-31-0
316.814
326.318
332.655
338.991
124
L-2-32-0
319.488
329.073
335.462
341.852
125
L-2-41-0
956.669
985.369
1.004.502
1.023.636
126
L-2-42-0

214.565
221.002
225.294
229.585
127
L-2-51-0
1.432.283
1.475.252
1.503.897
1.532.543
128
L-2-52-0

1.095.744
1.128.616
1.150.531
1.172.446

SALURAN PERNAFASAN
KECIL
PROSEDUR ADHESIOLYSIS PADA
PERITONEUM
FEMORALIS
USUS BESAR
ATAS

GASTROINTESTINAL
PADA LUKA BAKAR
LUKA BAKAR
TANPA LUKA BAKAR
TANPA LUKA BAKAR
Regional 1
Regional 2
- 517 No
Kode
INA-CBG
129
L-2-53-0
130
L-3-10-0
131
L-3-11-0
132
L-3-12-0
133
M-2-10-0
134
M-2-21-0
135
M-2-22-0
136
M-2-31-0
137
Deskripsi (INA-CBG)
PAYUDARA
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
185.730
191.302
195.017
198.731
252.609
260.187
265.240
270.292
245.301
252.660
257.566
262.472
186.820
192.425
196.161
199.897
1.512.902
1.558.289
1.588.547
1.618.805
1.354.908
1.395.555
1.422.653
1.449.752
329.860
339.756
346.353
352.950
PROSEDUR BUNION
822.971
847.660
864.119
880.578
M-2-32-0
260.810
268.634
273.850
279.067
138
M-2-41-0

TULANG
260.810
268.634
273.850
279.067
139
M-2-42-0
89.882
92.579
94.376
96.174
140
M-2-51-0
191.760
197.513
201.348
205.183
141
M-2-52-0
191.760
197.513
201.348
205.183
142
M-2-61-0
PROSEDUR ARTROSKOPI
939.915
968.113
986.911
1.005.709
191.760
197.513
201.348
205.183
945.000
973.350
992.250
1.011.150
1.288.785
1.327.448
1.353.224
1.379.000
191.760
197.513
201.348
205.183
951.462
980.006
999.035
1.018.064
918.201
945.747
964.111
982.475
1.369.234
1.410.311
1.437.695
1.465.080
994.660
1.024.500
1.044.393
1.064.287
191.760
197.513
201.348
205.183
191.760
197.513
201.348
205.183
547.320
563.739
574.686
585.632
303.455
312.559
318.628
324.697
686.241
706.828
720.553
734.278

DAN WAJAH
PROSEDUR BESAR PADA SENDI PANGGUL
DAN PAHA
PROSEDUR KECIL PADA SENDI PANGGUL
DAN PAHA
PROSEDUR LAIN-LAIN PADA SENDI &

TULANG
TULANG
WAJAH
WAJAH
BAWAH
BAWAH
BAHU
BAHU
PERGELANGAN TANGAN
PERGELANGAN TANGAN
143
M-2-62-0
144
M-2-63-0
145
M-2-64-0
146
M-2-65-0
147
M-2-71-0
148
M-2-72-0
149
M-2-81-0
150
M-2-82-0
151
M-2-83-0
152
M-2-84-0
153
M-3-10-0
154
M-3-11-0
155
M-3-12-0
156
M-3-13-0
223.733
230.445
234.920
239.394
157
M-3-14-0

TERTUTUP
382.398
393.870
401.517
409.165
158
M-3-15-0
168.470
173.524
176.893
180.262
159
M-3-16-0

191.760
197.513
201.348
205.183
160
M-3-17-0
209.354
215.634
219.822
224.009

MUSKULOSKELETAL
SKELETAL
- 518 No
Kode
INA-CBG
161
N-2-11-0
Deskripsi (INA-CBG)
EXTRACORPOREAL SHOCKWAVE
LITHOTRIPSY (ESWL) PADA SALURAN KEMIH
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.453.678
2.527.288
2.576.362
2.625.435
1.419.428
1.462.011
1.490.400
1.518.788
1.411.946
1.454.305
1.482.544
1.510.783
162
N-2-12-0
163
N-2-21-0
164
N-2-22-0
319.488
329.073
335.462
341.852
165
N-2-23-0

URETER
319.488
329.073
335.462
341.852
166
N-2-24-0
1.032.478
1.063.452
1.084.102
1.104.751
167
N-2-31-0
869.179
895.254
912.638
930.022
168
N-2-32-0
319.488
329.073
335.462
341.852
169
N-2-41-0
319.488
329.073
335.462
341.852
170
N-2-42-0
540.315
556.525
567.331
578.138
171
N-3-10-0
319.488
329.073
335.462
341.852
172
N-3-11-0
370.172
381.278
388.681
396.085
173
N-3-12-0
286.049
294.630
300.351
306.072
174
N-3-13-0
319.488
329.073
335.462
341.852
175
N-3-14-0
274.902
283.149
288.647
294.145
176
N-3-15-0
704.918
726.066
740.164
754.262
177
O-7-10-0
117.691
121.222
123.575
125.929
178
O-7-11-0
648.155
667.600
680.563
693.526
179
O-7-12-0
236.015
243.096
247.816
252.536
180
O-7-13-0
131.167
135.102
137.725
140.348
181
P-9-10-0
174.944
180.192
183.691
187.190
182
P-9-11-0
174.944
180.192
183.691
187.190
183
P-9-12-0
174.944
180.192
183.691
187.190
184
P-9-13-0
174.944
180.192
183.691
187.190
174.944
180.192
183.691
187.190
111.513
114.858
117.088
119.319
174.944
180.192
183.691
187.190

DAN URETHRA
DAN URETHRA
TRANSURETHRA
TRANSURETHRA
SALURAN KEMIH
SALURAN KEMIH
PROSEDUR KECIL ENDOSKOPI PADA
SALURAN KEMIH
PROSEDUR DIALISIS
CAESAR
VAGINAL/JALAN LAHIR
LAIN

ASPIRASI
185
P-9-14-0
186
P-9-15-0
187
P-9-16-0
188
P-9-17-0
174.191
179.417
182.901
186.385
189
Q-5-10-0
228.007
234.848
239.408
243.968
190
Q-5-11-0
PENYALAHGUNAAN ZAT KIMIA BUKAN

AKUT
170.885
176.012
179.430
182.847
191
Q-5-12-0
GIGI
150.614
155.132
158.144
161.157
No
Kode
INA-CBG
192
Q-5-13-0
MEDICAL CHECK-UP
114.460
193
Q-5-14-0
194
Q-5-15-0
195
Deskripsi (INA-CBG)
Regional 1
Regional 2
Regional 3
Regional 4
117.894
120.183
122.472
125.943
129.722
132.240
134.759
86.611
89.209
90.942
92.674
Q-5-16-0
VAKSINASI
97.891
100.827
102.785
104.743
196
Q-5-17-0
PASANG INFUS
84.673
87.213
88.906
90.600
197
Q-5-18-0
159.381
164.162
167.350
170.537
198
Q-5-19-0
178.178
183.523
187.087
190.651
199
Q-5-20-0
ABORSI MENGANCAM
119.427
123.010
125.398
127.787
200
Q-5-21-0
ABORSI
117.800
121.334
123.690
126.046
201
Q-5-22-0
125.943
129.722
132.240
134.759
202
Q-5-23-0
154.188
158.813
161.897
164.981
203
Q-5-24-0
105.308
108.467
110.573
112.680
204
Q-5-25-0
164.226
169.153
172.437
175.722
205
Q-5-26-0
BRONKIAL AKUT
232.450
239.424
244.073
248.722
206
Q-5-27-0
165.423
170.386
173.694
177.003
207
Q-5-28-0
134.236
138.264
140.948
143.633
208
Q-5-29-0

JANTUNG LAIN-LAIN
380.046
391.447
399.048
406.649
209
Q-5-30-0
440.432
453.645
462.453
471.262
210
Q-5-31-0
FRAKTUR
157.128
161.842
164.985
168.127
211
Q-5-32-0
SALURAN KEMIH AKUT
181.990
187.450
191.090
194.729
212
Q-5-33-0
HEMATOLOGI AKUT
190.543
196.259
200.070
203.881
213
Q-5-34-0
INFEKSI VIRUS HIV
270.680
278.800
284.214
289.627
214
Q-5-35-0
INFEKSI AKUT
306.943
316.152
322.291
328.430
215
Q-5-36-0
357.456
368.179
375.328
382.477
216
Q-5-37-0

SHOCK
182.321
187.790
191.437
195.083
217
Q-5-38-0
PARU AKUT
243.130
250.424
255.287
260.150
218
Q-5-39-0
KECEDERAAN BESAR PADA JARINGAN

LUNAK
155.586
160.253
163.365
166.477
219
Q-5-40-0
152.654
157.234
160.287
163.340
220
Q-5-41-0
211.328
217.668
221.895
226.121
221
Q-5-42-0
165.690
170.660
173.974
177.288
222
Q-5-43-0
238.603
245.761
250.533
255.305
223
Q-5-44-0
194.733
200.575
204.470
208.364
224
T-2-10-0

TERAPI DETOKSIKASI
101.005
104.035
106.055
108.075
225
U-2-10-0
1.348.022
1.388.463
1.415.423
1.442.384
- 520 No
Kode
INA-CBG
226
U-2-11-0
PROSEDUR BESAR LAIN-LAIN PADA KEPALA

& LEHER
227
U-2-12-0
228
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.602.274
1.650.343
1.682.388
1.714.434
176.292
181.581
185.107
188.632
U-2-13-0
231.123
238.057
242.679
247.302
229
U-2-14-0

LANGIT-LANGIT MULUT
429.322
442.202
450.788
459.375
230
U-2-15-0
243.931
251.249
256.128
261.007
231
U-2-21-0
284.142
292.666
298.349
304.032
232
U-2-22-0
548.985
565.455
576.434
587.414
233
U-2-23-0
719.348
740.928
755.315
769.702
234
U-2-24-0
606.254
624.442
636.567
648.692
235
U-2-25-0
231.123
238.057
242.679
247.302
236
U-2-31-0
185.730
191.302
195.017
198.731
237
U-2-32-0
231.123
238.057
242.679
247.302
220.966
227.595
232.014
236.434
234.597
241.635
246.327
251.019
103.738
106.851
108.925
111.000
228.025
234.866
239.427
243.987
209.508
215.793
219.984
224.174
182.710
188.191
191.845
195.499
206.063
212.245
216.367
220.488
2.010.387
2.070.699
2.110.907
2.151.114
226.721
233.522
238.057
242.591
723.497
745.202
759.672
774.142
319.488
329.073
335.462
341.852
319.488
329.073
335.462
341.852

(RHINOPLASTY)

TENGGOROKAN
RONGGA HIDUNG
TENGGOROKAN
238
U-3-10-0
239
U-3-11-0
240
U-3-12-0
241
U-3-13-0
242
U-3-14-0
243
U-3-15-0
244
U-3-16-0
PROSEDUR PADA GIGI
245
V-2-10-0

PROSTAT
246
V-2-11-0
PROSEDUR PADA PENIS

SKROTUM
SKROTUM
TRANSURETHRAL
247
V-2-12-0
248
V-2-13-0
249
V-2-14-0
250
V-2-15-0
SIRKUMSISI/SUNAT
174.944
180.192
183.691
187.190
251
V-3-10-0
364.857
375.802
383.100
390.397
252
V-3-11-0
771.861
795.017
810.454
825.891
253
V-3-12-0
445.616
458.984
467.897
476.809
254
W-2-10-0
163.172
168.067
171.331
174.594
255
W-2-11-0
417.007
429.518
437.858
446.198
256
W-2-12-0
771.861
795.017
810.454
825.891

PROSEDUR ABORSI
RAHIM & LEHER RAHIM
TERHALANG/TERGANGGU
- 521 No
Kode
INA-CBG
257
W-2-13-0
258
W-2-21-0
259
W-2-22-0
260
W-2-23-0
261
W-2-31-0
262
W-2-32-0
263
W-2-33-0
264
Deskripsi (INA-CBG)
TERHALANG/TERGANGGU
PANGGUL TERBUKA
PANGGUL TERBUKA
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
123.793
127.507
129.982
132.458
1.551.647
1.598.196
1.629.229
1.660.262
163.172
168.067
171.331
174.594
544.514
560.849
571.739
582.630
1.787.473
1.841.097
1.876.846
1.912.596
1.253.636
1.291.245
1.316.317
1.341.390
532.812
548.796
559.452
570.109
W-2-34-0
181.219
186.655
190.280
193.904
265
W-3-10-0
440.431
453.644
462.453
471.262
266
W-3-11-0
352.068
362.630
369.672
376.713
267
W-3-12-0
163.172
168.067
171.331
174.594
268
Z-3-10-0
1.847.327
1.902.747
1.939.693
1.976.640
269
Z-3-11-0
LITHOTRIPSY (ESWL) SELAIN URINARI DAN
SALURAN EMPEDU
1.411.946
1.454.305
1.482.544
1.510.783
270
Z-3-12-0
235.761
242.834
247.549
252.264
271
Z-3-13-0

LAIN-LAIN
1.438.678
1.481.838
1.510.611
1.539.385
272
Z-3-14-0
DIAGNOSTIK TIDUR
284.471
293.005
298.695
304.384
273
Z-3-15-0
185.730
191.302
195.017
198.731
274
Z-3-16-0

(MRI)
596.137
614.022
625.944
637.867
275
Z-3-17-0
PENGOBATAN NUKLIR
250.271
257.780
262.785
267.790
276
Z-3-18-0
CT-SCAN KEPALA
241.132
248.366
253.188
258.011
277
Z-3-19-0
CT SCAN LAIN-LAIN
250.971
258.500
263.520
268.539
278
Z-3-20-0
170.692
175.812
179.226
182.640
279
Z-3-21-0
163.172
168.067
171.331
174.594
280
Z-3-22-0
183.962
189.481
193.160
196.839
281
Z-3-23-0
191.612
197.361
201.193
205.025
282
Z-3-24-0
376.480
387.775
395.304
402.834
283
Z-3-25-0
167.684
172.714
176.068
179.422
284
Z-3-26-0
189.516
195.201
198.992
202.782
285
Z-3-27-0
PERAWATAN LUKA
180.936
186.364
189.983
193.602
286
Z-3-28-0
IMAGING PAYUDARA
185.730
191.302
195.017
198.731
287
Z-3-29-0
IMAGING LAIN-LAIN
535.308
551.367
562.073
572.779
288
Z-3-30-0
FOTOTERAPI
90.340
93.050
94.857
96.664

JALAN LAHIR
- 522 3. RUMAH SAKIT MATAKELAS B NON PENDIDIKAN

a. RawatInap
No
Kode
INA-CBG
A-4-10-i
SEPTIKEMIA RINGAN
A-4-10-ii
A-4-10-iii
A-4-11-i
A-4-11-ii
A-4-11-iii
A-4-12-i
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
2.174.376
2.239.607
2.283.095
2.326.582
SEPTIKEMIA SEDANG
2.489.076
2.563.749
2.613.530
2.663.312
SEPTIKEMIA BERAT
3.902.402
4.019.474
4.097.522
4.175.570
3.907.861
4.025.097
4.103.254
4.181.412
6.037.194
6.218.310
6.339.054
6.459.798
9.875.531
10.171.797
10.369.307
10.566.818
DEMAM RINGAN
1.532.986
1.578.975
1.609.635
1.640.295
A-4-12-ii
DEMAM SEDANG
2.198.736
2.264.699
2.308.673
2.352.648
A-4-12-iii
DEMAM BERAT
2.516.293
2.591.781
2.642.107
2.692.433
10
A-4-13-i
1.916.232
1.973.719
2.012.044
2.050.369
11
A-4-13-ii
2.299.479
2.368.463
2.414.453
2.460.442
12
A-4-13-iii
2.794.745
2.878.587
2.934.482
2.990.377
13
A-4-14-i
1.532.986
1.578.975
1.609.635
1.640.295
14
A-4-14-ii
2.434.702
2.507.743
2.556.437
2.605.131
15
A-4-14-iii
2.772.448
2.855.621
2.911.070
2.966.519
16
A-4-15-i
INFEKSI HIV RINGAN
2.299.479
2.368.463
2.414.453
2.460.442
17
A-4-15-ii
INFEKSI HIV SEDANG
3.449.218
3.552.695
3.621.679
3.690.664
18
A-4-15-iii
INFEKSI HIV BERAT
4.797.050
4.940.962
5.036.903
5.132.844
19
B-1-01-i
25.493.308
26.258.107
26.767.974
27.277.840
20
B-1-01-ii
28.125.935
28.969.713
29.532.231
30.094.750
21
B-1-01-iii
49.338.677
50.818.837
51.805.611
52.792.384
22
B-1-10-i
3.305.121
3.404.275
3.470.377
3.536.479
23
B-1-10-ii
8.423.040
8.675.731
8.844.192
9.012.653
24
B-1-10-iii
14.661.180
15.101.015
15.394.239
15.687.463
25
B-1-11-i
2.259.482
2.327.266
2.372.456
2.417.646
26
B-1-11-ii
5.671.513
5.841.658
5.955.088
6.068.519
27
B-1-11-iii
7.110.670
7.323.990
7.466.203
7.608.416
28
B-1-12-i
4.819.556
4.964.143
5.060.534
5.156.925
29
B-1-12-ii
10.329.488
10.639.373
10.845.963
11.052.553
30
B-1-12-iii
12.571.377
12.948.518
13.199.945
13.451.373

RINGAN
SEDANG
BERAT

LAIN-LAIN RINGAN
LAIN-LAIN SEDANG
LAIN-LAIN BERAT

(RINGAN)
(SEDANG)
(BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT
Regional 1
- 523 No
Kode
INA-CBG
31
B-1-13-i
32
B-1-13-ii
33
B-1-13-iii
34
B-1-14-i
35
B-1-14-ii
36
B-1-14-iii
37
B-4-10-i
38
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
3.158.148
3.252.892
3.316.055
3.379.218
5.144.165
5.298.490
5.401.373
5.504.256
7.583.942
7.811.461
7.963.140
8.114.818
4.288.543
4.417.199
4.502.970
4.588.741
4.769.725
4.912.817
5.008.211
5.103.606
7.461.668
7.685.518
7.834.751
7.983.985
1.199.364
1.235.345
1.259.332
1.283.320
B-4-10-ii
1.916.232
1.973.719
2.012.044
2.050.369
39
B-4-10-iii
2.929.692
3.017.583
3.076.176
3.134.770
40
B-4-11-i
2.896.934
2.983.842
3.041.780
3.099.719
41
B-4-11-ii
4.404.062
4.536.184
4.624.266
4.712.347
42
B-4-11-iii
4.743.328
4.885.628
4.980.495
5.075.361
43
B-4-12-i
2.541.861
2.618.117
2.668.954
2.719.791
44
B-4-12-ii
3.603.733
3.711.845
3.783.920
3.855.994
45
B-4-12-iii
7.004.179
7.214.304
7.354.388
7.494.471
46
B-4-13-i
2.299.479
2.368.463
2.414.453
2.460.442
47
B-4-13-ii
3.588.463
3.696.117
3.767.886
3.839.655
48
B-4-13-iii
5.446.525
5.609.921
5.718.852
5.827.782
49
B-4-14-i
2.299.479
2.368.463
2.414.453
2.460.442
50
B-4-14-ii
2.682.725
2.763.207
2.816.862
2.870.516
51
B-4-14-iii
3.579.026
3.686.396
3.757.977
3.829.557
52
C-4-10-i
2.239.228
2.306.405
2.351.190
2.395.974
53
C-4-10-ii
4.350.586
4.481.103
4.568.115
4.655.127
54
C-4-10-iii
LEUKEMIA AKUT BERAT
7.281.683
7.500.134
7.645.767
7.791.401
55
C-4-11-i
2.299.479
2.368.463
2.414.453
2.460.442
56
C-4-11-ii
3.065.972
3.157.951
3.219.270
3.280.590
57
C-4-11-iii
5.212.511
5.368.886
5.473.137
5.577.387
58
C-4-12-i
RADIOTERAPI RINGAN
1.532.986
1.578.975
1.609.635
1.640.295
59
C-4-12-ii
RADIOTERAPI SEDANG
4.220.773
4.347.396
4.431.812
4.516.227
60
C-4-12-iii
RADIOTERAPI BERAT
8.569.015
8.826.086
8.997.466
9.168.846
61
C-4-13-i
KEMOTERAPI RINGAN
1.532.986
1.578.975
1.609.635
1.640.295
62
C-4-13-ii
KEMOTERAPI SEDANG
3.065.972
3.157.951
3.219.270
3.280.590
63
C-4-13-iii
KEMOTERAPI BERAT
4.011.597
4.131.945
4.212.177
4.292.409

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT

PANCREAS RINGAN
PANCREAS SEDANG
PANCREAS BERAT
(RINGAN)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT
Regional 1
- 524 No
Kode
INA-CBG
64
C-4-14-i
65
C-4-14-ii
66
C-4-14-iii
67
D-1-10-i
68
D-1-10-ii
69
D-1-10-iii
70
D-1-11-i
71
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
1.987.873
2.047.509
2.087.266
2.127.024
2.904.806
2.991.951
3.050.047
3.108.143
4.428.293
4.561.142
4.649.708
4.738.274
16.312.788
16.802.172
17.128.428
17.454.683
24.845.628
25.590.997
26.087.909
26.584.822
33.672.615
34.682.793
35.356.245
36.029.698
3.352.953
3.453.542
3.520.601
3.587.660
D-1-11-ii
8.745.118
9.007.471
9.182.374
9.357.276
72
D-1-11-iii
12.390.395
12.762.107
13.009.914
13.257.722
73
D-1-20-i
4.130.132
4.254.036
4.336.638
4.419.241
74
D-1-20-ii
9.292.796
9.571.580
9.757.436
9.943.292
75
D-1-20-iii
16.798.267
17.302.215
17.638.181
17.974.146
76
D-4-10-i
1.472.527
1.516.703
1.546.153
1.575.604
77
D-4-10-ii
2.973.309
3.062.509
3.121.975
3.181.441
78
D-4-10-iii
3.832.465
3.947.439
4.024.088
4.100.737
79
D-4-11-i
3.353.407
3.454.009
3.521.077
3.588.145
80
D-4-11-ii
5.993.440
6.173.243
6.293.112
6.412.981
81
D-4-11-iii
8.205.378
8.451.540
8.615.647
8.779.755
82
D-4-12-i
1.965.689
2.024.660
2.063.973
2.103.287
83
D-4-12-ii
2.726.604
2.808.402
2.862.934
2.917.466
84
D-4-12-iii
4.186.701
4.312.302
4.396.036
4.479.770
85
D-4-13-i
1.532.986
1.578.975
1.609.635
1.640.295
86
D-4-13-ii
2.299.479
2.368.463
2.414.453
2.460.442
87
D-4-13-iii
2.682.725
2.763.207
2.816.862
2.870.516
88
D-4-14-i
1.847.061
1.902.473
1.939.414
1.976.355
89
D-4-14-ii
4.312.436
4.441.809
4.528.058
4.614.306
90
D-4-14-iii
5.144.139
5.298.463
5.401.346
5.504.229
91
E-1-01-i
3.674.729
3.784.971
3.858.466
3.931.960
92
E-1-01-ii
4.813.546
4.957.952
5.054.223
5.150.494
93
E-1-01-iii
10.910.013
11.237.313
11.455.514
11.673.714
94
E-1-10-i
3.744.352
3.856.683
3.931.570
4.006.457
95
E-1-10-ii
4.544.765
4.681.108
4.772.003
4.862.898
96
E-1-10-iii
9.579.026
9.866.397
10.057.978
10.249.558

RINGAN
SEDANG
BERAT
TULANG RINGAN
TULANG SEDANG
TULANG BERAT


RINGAN
SEDANG
BERAT
Regional 1
- 525 No
Kode
INA-CBG
97
E-1-20-i
98
E-1-20-ii
99
E-1-20-iii
100
E-4-10-i
101
E-4-10-ii
102
E-4-10-iii
103
E-4-11-i
104
E-4-11-ii
105
E-4-11-iii
106
E-4-12-i
107
108
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
4.336.038
4.466.119
4.552.840
4.639.560
5.807.422
5.981.644
6.097.793
6.213.941
12.867.606
13.253.634
13.510.986
13.768.338
1.916.232
1.973.719
2.012.044
2.050.369
2.725.286
2.807.044
2.861.550
2.916.056
5.209.330
5.365.610
5.469.797
5.573.983
1.634.947
1.683.995
1.716.694
1.749.393
3.093.039
3.185.830
3.247.691
3.309.552
5.100.564
5.253.581
5.355.592
5.457.603
1.953.533
2.012.139
2.051.210
2.090.281
E-4-12-ii
3.393.655
3.495.465
3.563.338
3.631.211
E-4-12-iii
5.541.579
5.707.827
5.818.658
5.929.490
2.060.595
2.122.413
2.163.625
2.204.837
3.538.056
3.644.198
3.714.959
3.785.720
6.121.731
6.305.383
6.427.818
6.550.252

RINGAN
SEDANG
BERAT
GANGGUAN KELENJAR ENDOKRIN LAINLAIN RINGAN

GANGGUAN KELENJAR ENDOKRIN LAINLAIN SEDANG
GANGGUAN KELENJAR ENDOKRIN LAINLAIN BERAT
Regional 1
109
E-4-13-i
110
E-4-13-ii
111
E-4-13-iii
112
F-4-10-i
SCHIZOFRENIA RINGAN
2.519.467
2.595.051
2.645.441
2.695.830
113
F-4-10-ii
SCHIZOFRENIA SEDANG
2.797.950
2.881.888
2.937.847
2.993.806
114
F-4-10-iii
SCHIZOFRENIA BERAT
4.142.426
4.266.699
4.349.547
4.432.396
115
F-4-11-i
2.322.339
2.392.009
2.438.456
2.484.902
116
F-4-11-ii
2.705.745
2.786.917
2.841.032
2.895.147
117
F-4-11-iii
DEPRESI MAYOR BERAT
3.469.754
3.573.847
3.643.242
3.712.637
1.149.739
1.184.232
1.207.226
1.230.221
1.641.665
1.690.915
1.723.748
1.756.581
3.561.316
3.668.156
3.739.382
3.810.609

IMPULSE RINGAN
IMPULSE SEDANG
IMPULSE BERAT
118
F-4-12-i
119
F-4-12-ii
120
F-4-12-iii
121
F-4-13-i
1.876.802
1.933.107
1.970.643
2.008.179
122
F-4-13-ii
2.485.369
2.559.930
2.609.637
2.659.345
123
F-4-13-iii
3.204.566
3.300.703
3.364.794
3.428.885
124
F-4-14-i
DEPRESI RINGAN
1.313.762
1.353.175
1.379.450
1.405.725
125
F-4-14-ii
DEPRESI SEDANG
1.685.166
1.735.721
1.769.424
1.803.127
126
F-4-14-iii
DEPRESI BERAT
2.267.466
2.335.490
2.380.839
2.426.188
127
F-4-15-i
1.561.988
1.608.848
1.640.087
1.671.327
128
F-4-15-ii
2.299.479
2.368.463
2.414.453
2.460.442
129
F-4-15-iii
3.028.555
3.119.411
3.179.982
3.240.554
- 526 No
Kode
INA-CBG
130
F-4-16-i
131
F-4-16-ii
132
F-4-16-iii
133
F-4-17-i
134
F-4-17-ii
135
F-4-17-iii
136
F-4-18-i
137
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
3.364.216
3.465.143
3.532.427
3.599.712
3.910.817
4.028.142
4.106.358
4.184.575
5.220.288
5.376.897
5.481.303
5.585.708
776.758
800.060
815.596
831.131
2.276.603
2.344.901
2.390.433
2.435.965
2.428.968
2.501.837
2.550.416
2.598.996
2.915.989
3.003.469
3.061.789
3.120.109
F-4-18-ii
3.208.412
3.304.664
3.368.833
3.433.001
138
F-4-18-iii
4.946.047
5.094.428
5.193.349
5.292.270
139
F-4-19-i
2.236.289
2.303.377
2.348.103
2.392.829
140
F-4-19-ii
2.863.625
2.949.534
3.006.807
3.064.079
141
F-4-19-iii
3.565.252
3.672.209
3.743.514
3.814.819
142
G-1-01-i
7.109.639
7.322.928
7.465.121
7.607.314
143
G-1-01-ii
12.033.921
12.394.938
12.635.617
12.876.295
144
G-1-01-iii
23.296.327
23.995.216
24.461.143
24.927.069
145
G-1-10-i
3.548.069
3.654.511
3.725.472
3.796.433
146
G-1-10-ii
5.008.991
5.159.260
5.259.440
5.359.620
147
G-1-10-iii
5.936.724
6.114.826
6.233.560
6.352.294
148
G-1-11-i
4.092.803
4.215.587
4.297.443
4.379.299
149
G-1-11-ii
8.404.879
8.657.026
8.825.123
8.993.221
150
G-1-11-iii
17.599.053
18.127.024
18.479.005
18.830.986
151
G-1-12-i
3.182.995
3.278.485
3.342.145
3.405.804
152
G-1-12-ii
7.287.150
7.505.764
7.651.507
7.797.250
153
G-1-12-iii
12.852.934
13.238.522
13.495.581
13.752.639
154
G-1-13-i
839.455
864.639
881.428
898.217
155
G-1-13-ii
2.254.684
2.322.324
2.367.418
2.412.512
156
G-1-13-iii
5.087.516
5.240.142
5.341.892
5.443.642
157
G-1-20-i
4.010.844
4.131.169
4.211.386
4.291.603
158
G-1-20-ii
5.418.782
5.581.345
5.689.721
5.798.097
159
G-1-20-iii
13.267.250
13.665.268
13.930.613
14.195.958
160
G-1-30-i
5.115.471
5.268.935
5.371.244
5.473.554
161
G-1-30-ii
13.351.869
13.752.425
14.019.463
14.286.500
162
G-1-30-iii
17.187.982
17.703.621
18.047.381
18.391.140

RINGAN
SEDANG
BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT
RINGAN
SEDANG
RINGAN
SEDANG
BERAT
Regional 1
- 527 No
Kode
INA-CBG
163
G-4-10-i
164
G-4-10-ii
165
G-4-10-iii
166
G-4-11-i
167
G-4-11-ii
168
G-4-11-iii
169
G-4-12-i
170
G-4-12-ii
171
G-4-12-iii
172
G-4-13-i
173
G-4-13-ii
174
G-4-13-iii
175
G-4-14-i
176
G-4-14-ii
177
G-4-14-iii
178
G-4-15-i
179
G-4-15-ii
180
G-4-15-iii
181
G-4-16-i
182
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
2.299.479
2.368.463
2.414.453
2.460.442
2.682.725
2.763.207
2.816.862
2.870.516
4.098.460
4.221.414
4.303.383
4.385.353
4.775.382
4.918.644
5.014.151
5.109.659
5.539.443
5.705.627
5.816.415
5.927.204
8.118.150
8.361.694
8.524.057
8.686.420
2.837.560
2.922.686
2.979.438
3.036.189
3.575.325
3.682.585
3.754.091
3.825.598
5.192.734
5.348.516
5.452.371
5.556.226
1.578.799
1.626.163
1.657.739
1.689.315
2.682.725
2.763.207
2.816.862
2.870.516
3.171.362
3.266.503
3.329.930
3.393.358
2.887.388
2.974.010
3.031.758
3.089.506
4.750.728
4.893.250
4.988.265
5.083.279
5.948.020
6.126.461
6.245.421
6.364.381
2.955.326
3.043.986
3.103.092
3.162.199
3.571.068
3.678.200
3.749.622
3.821.043
4.412.866
4.545.252
4.633.510
4.721.767
1.916.232
1.973.719
2.012.044
2.050.369
G-4-16-ii
2.865.743
2.951.715
3.009.030
3.066.345
183
G-4-16-iii
5.200.811
5.356.836
5.460.852
5.564.868
184
G-4-17-i
2.738.471
2.820.625
2.875.395
2.930.164
185
G-4-17-ii
3.398.563
3.500.520
3.568.492
3.636.463
186
G-4-17-iii
5.696.020
5.866.901
5.980.821
6.094.742
187
G-4-18-i
2.299.479
2.368.463
2.414.453
2.460.442
188
G-4-18-ii
3.297.055
3.395.966
3.461.907
3.527.848
189
G-4-18-iii
3.492.894
3.597.681
3.667.538
3.737.396
190
G-4-19-i
1.916.232
1.973.719
2.012.044
2.050.369
191
G-4-19-ii
3.883.503
4.000.008
4.077.678
4.155.348

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
DEGENERATIF RINGAN
DEGENERATIF SEDANG
DEGENERATIF BERAT
RINGAN
SEDANG
BERAT
TRAUMATIK RINGAN
TRAUMATIK SEDANG
TRAUMATIK BERAT
DENGAN INFARK BERAT
NON SPESIFIK & PENYUMBATAN PRECEREBRAL TANPA INFARK RINGAN
NON SPESIFIK & PENYUMBATAN PRECEREBRAL TANPA INFARK SEDANG
NON SPESIFIK & PENYUMBATAN PRECEREBRAL TANPA INFARK BERAT

PERIFER RINGAN
PERIFER SEDANG
PERIFER BERAT
PERSARAFAN RINGAN
PERSARAFAN SEDANG
PERSARAFAN BERAT
RINGAN
SEDANG
Regional 1
- 528 No
Kode
INA-CBG
192
G-4-19-iii

BERAT
193
G-4-20-i
194
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
5.792.953
5.966.742
6.082.601
6.198.460
1.341.363
1.381.604
1.408.431
1.435.258
G-4-20-ii
1.904.736
1.961.879
1.999.973
2.038.068
195
G-4-20-iii
3.248.022
3.345.463
3.410.423
3.475.383
196
G-4-21-i
1.554.333
1.600.963
1.632.049
1.663.136
197
G-4-21-ii
3.219.178
3.315.754
3.380.137
3.444.521
198
G-4-21-iii
3.792.572
3.906.349
3.982.200
4.058.052
199
G-4-22-i
1.532.986
1.578.975
1.609.635
1.640.295
200
G-4-22-ii
1.916.232
1.973.719
2.012.044
2.050.369
201
G-4-22-iii
2.198.419
2.264.372
2.308.340
2.352.309
202
G-4-23-i
1.532.986
1.578.975
1.609.635
1.640.295
203
G-4-23-ii
1.916.232
1.973.719
2.012.044
2.050.369
204
G-4-23-iii
2.739.118
2.821.292
2.876.074
2.930.857
205
G-4-24-i
1.532.986
1.578.975
1.609.635
1.640.295
206
G-4-24-ii
1.916.232
1.973.719
2.012.044
2.050.369
207
G-4-24-iii
TRAUMA KEPALA BERAT
4.026.755
4.147.558
4.228.093
4.308.628
208
G-4-25-i
GEGAR OTAK RINGAN
1.456.636
1.500.335
1.529.468
1.558.600
209
G-4-25-ii
GEGAR OTAK SEDANG
1.833.937
1.888.955
1.925.634
1.962.312
210
G-4-25-iii
GEGAR OTAK BERAT
2.392.780
2.464.564
2.512.419
2.560.275
2.299.479
2.368.463
2.414.453
2.460.442
2.682.725
2.763.207
2.816.862
2.870.516
5.120.947
5.274.576
5.376.995
5.479.414
2.501.758
2.576.810
2.626.846
2.676.881
4.562.238
4.699.105
4.790.350
4.881.595
6.204.359
6.390.490
6.514.577
6.638.664
2.449.459
2.522.943
2.571.932
2.620.921
2.792.383
2.876.155
2.932.002
2.987.850
4.658.991
4.798.760
4.891.940
4.985.120

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
RINGAN
SEDANG
Regional 1
211
G-4-26-i
212
G-4-26-ii
213
G-4-26-iii
214
H-1-20-i
215
H-1-20-ii
216
H-1-20-iii
217
H-1-30-i
218
H-1-30-ii
219
H-1-30-iii
220
H-4-10-i
2.894.297
2.981.126
3.039.012
3.096.897
221
H-4-10-ii
4.823.828
4.968.543
5.065.019
5.161.496
222
H-4-10-iii
7.864.264
8.100.192
8.257.477
8.414.763
223
H-4-11-i
1.929.531
1.987.417
2.026.008
2.064.598
224
H-4-11-ii
2.201.962
2.268.020
2.312.060
2.356.099

RINGAN
SEDANG
BERAT
- 529 No
Kode
INA-CBG
225
H-4-11-iii
226
H-4-12-i
227
H-4-12-ii
228
H-4-12-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
3.148.599
3.243.057
3.306.029
3.369.001
2.466.374
2.540.365
2.589.693
2.639.020
3.340.865
3.441.091
3.507.908
3.574.725
5.574.005
5.741.225
5.852.705
5.964.185
33.072.334
34.064.505
34.725.951
35.387.398
33.800.098
34.814.101
35.490.103
36.166.105
53.352.807
54.953.391
56.020.447
57.087.503
18.348.341
18.898.791
19.265.758
19.632.725
23.669.359
24.379.440
24.852.827
25.326.215
29.173.862
30.049.078
30.632.555
31.216.032
11.299.561
11.638.548
11.864.539
12.090.530
15.487.993
15.952.633
16.262.393
16.572.153
22.715.724
23.397.195
23.851.510
24.305.824
13.785.133
14.198.687
14.474.390
14.750.093
17.707.248
18.238.466
18.592.611
18.946.756
37.748.177
38.880.622
39.635.586
40.390.550
24.284.569
25.013.106
25.498.797
25.984.488
29.141.482
30.015.727
30.598.556
31.181.386
40.098.496
41.301.451
42.103.420
42.905.390

ATAU/DAN JANTUNG RINGAN
ATAU/DAN JANTUNG SEDANG
ATAU/DAN JANTUNG BERAT
KATETERISASI RINGAN
KATETERISASI SEDANG
KATETERISASI BERAT
RINGAN
SEDANG
Regional 1
229
I-1-01-i
230
I-1-01-ii
231
I-1-01-iii
232
I-1-02-i
233
I-1-02-ii
234
I-1-02-iii
235
I-1-03-i
236
I-1-03-ii
237
I-1-03-iii
238
I-1-04-i
239
I-1-04-ii
240
I-1-04-iii
241
I-1-05-i
242
I-1-05-ii
243
I-1-05-iii
244
I-1-06-i
11.447.207
11.790.623
12.019.567
12.248.511
245
I-1-06-ii
17.276.553
17.794.849
18.140.380
18.485.911
246
I-1-06-iii
22.241.100
22.908.333
23.353.155
23.797.977
247
I-1-07-i
15.053.944
15.505.562
15.806.641
16.107.720
248
I-1-07-ii
18.572.098
19.129.261
19.500.703
19.872.145
249
I-1-07-iii
20.262.038
20.869.899
21.275.140
21.680.381
250
I-1-11-i
2.863.627
2.949.536
3.006.809
3.064.081
251
I-1-11-ii
3.184.067
3.279.589
3.343.270
3.406.952
252
I-1-11-iii
4.237.023
4.364.134
4.448.874
4.533.614

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
RINGAN
SEDANG
BERAT
- 530 No
Kode
INA-CBG
253
I-1-12-i
254
I-1-12-ii
255
I-1-12-iii
256
I-1-13-i
257
I-1-13-ii
258
I-1-13-iii
259
I-1-14-i
260
I-1-14-ii
261
I-1-14-iii
262
I-1-15-i
263
I-1-15-ii
264
I-1-15-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
8.776.530
9.039.825
9.215.356
9.390.887
12.177.845
12.543.180
12.786.737
13.030.294
16.985.218
17.494.775
17.834.479
18.174.184
5.162.664
5.317.544
5.420.798
5.524.051
6.006.444
6.186.637
6.306.766
6.426.895
10.949.345
11.277.826
11.496.813
11.715.799
18.887.998
19.454.638
19.832.398
20.210.158
23.475.083
24.179.335
24.648.837
25.118.339
30.760.453
31.683.267
32.298.476
32.913.685
3.701.142
3.812.176
3.886.199
3.960.222
10.841.595
11.166.843
11.383.675
11.600.507
56.117.717
57.801.248
58.923.602
60.045.957
8.094.856
8.337.702
8.499.599
8.661.496
21.046.626
21.678.025
22.098.957
22.519.890
24.276.767
25.005.070
25.490.605
25.976.140
2.596.085
2.673.968
2.725.890
2.777.811
5.377.434
5.538.757
5.646.306
5.753.855
31.175.092
32.110.345
32.733.847
33.357.349
3.097.599
3.190.527
3.252.478
3.314.430
5.575.677
5.742.948
5.854.461
5.965.975
7.434.237
7.657.264
7.805.949
7.954.633
9.183.656
9.459.166
9.642.839
9.826.512
19.103.861
19.676.976
20.059.054
20.441.131
29.604.045
30.492.167
31.084.248
31.676.329
12.349.948
12.720.446
12.967.445
13.214.444
17.151.424
17.665.967
18.008.996
18.352.024
21.491.521
22.136.267
22.566.097
22.995.927

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

PEMBULUH DARAH VENA RINGAN
PEMBULUH DARAH VENA SEDANG
PEMBULUH DARAH VENA BERAT
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
Regional 1
265
I-1-16-i
266
I-1-16-ii
267
I-1-16-iii
268
I-1-17-i
269
I-1-17-ii
270
I-1-17-iii
271
I-1-20-i
272
I-1-20-ii
273
I-1-20-iii
274
I-1-30-i
275
I-1-30-ii
276
I-1-30-iii
277
I-1-40-i
278
I-1-40-ii
279
I-1-40-iii
280
I-4-10-i
3.591.724
3.699.475
3.771.310
3.843.144
281
I-4-10-ii
5.671.396
5.841.538
5.954.966
6.068.394
- 531 No
Kode
INA-CBG
282
I-4-10-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
8.181.483
8.426.928
8.590.558
8.754.187
4.258.845
4.386.610
4.471.787
4.556.964
5.270.337
5.428.447
5.533.854
5.639.261
283
I-4-11-i
284
I-4-11-ii
285
I-4-11-iii
9.327.246
9.607.063
9.793.608
9.980.153
286
I-4-12-i
3.730.305
3.842.215
3.916.821
3.991.427
287
I-4-12-ii
5.323.135
5.482.829
5.589.292
5.695.755
288
I-4-12-iii
6.457.712
6.651.443
6.780.598
6.909.752
289
I-4-13-i
3.350.840
3.451.365
3.518.382
3.585.399
290
I-4-13-ii
4.868.086
5.014.129
5.111.491
5.208.852
291
I-4-13-iii
9.964.408
10.263.341
10.462.629
10.661.917
292
I-4-14-i
2.083.913
2.146.430
2.188.108
2.229.787
293
I-4-14-ii
2.438.486
2.511.641
2.560.410
2.609.180
294
I-4-14-iii
3.778.842
3.892.208
3.967.784
4.043.361
295
I-4-15-i
3.065.972
3.157.951
3.219.270
3.280.590
296
I-4-15-ii
4.389.090
4.520.763
4.608.545
4.696.327
297
I-4-15-iii
5.002.507
5.152.582
5.252.633
5.352.683
298
I-4-16-i
2.299.479
2.368.463
2.414.453
2.460.442
299
I-4-16-ii
3.726.663
3.838.463
3.912.996
3.987.530
300
I-4-16-iii
4.694.934
4.835.782
4.929.681
5.023.579
301
I-4-17-i
HIPERTENSI RINGAN
2.057.986
2.119.726
2.160.885
2.202.045
302
I-4-17-ii
HIPERTENSI SEDANG
2.914.313
3.001.742
3.060.029
3.118.315
303
I-4-17-iii
HIPERTENSI BERAT
3.545.401
3.651.763
3.722.671
3.793.579
304
I-4-18-i
3.030.822
3.121.747
3.182.363
3.242.980
305
I-4-18-ii
4.643.017
4.782.307
4.875.168
4.968.028
306
I-4-18-iii
6.259.531
6.447.317
6.572.507
6.697.698
307
I-4-19-i
2.372.016
2.443.176
2.490.616
2.538.057
308
I-4-19-ii
3.885.287
4.001.846
4.079.552
4.157.257
309
I-4-19-iii
4.631.227
4.770.164
4.862.788
4.955.413
310
I-4-20-i
2.878.777
2.965.140
3.022.716
3.080.291
311
I-4-20-ii
3.316.566
3.416.063
3.482.394
3.548.726
312
I-4-20-iii
4.401.635
4.533.684
4.621.717
4.709.750
313
I-4-21-i
3.828.307
3.943.157
4.019.723
4.096.289
314
I-4-21-ii
4.775.565
4.918.832
5.014.343
5.109.855
THROMBOPHLEBITIS PADA PEMBULUH

DARAH VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
RINGAN
SEDANG
LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)

RINGAN
SEDANG
KONGENITAL BERAT
JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
RINGAN
SEDANG
- 532 No
Kode
INA-CBG
315
I-4-21-iii
316
I-4-22-i
317
I-4-22-ii
318
I-4-22-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
6.514.883
6.710.330
6.840.628
6.970.925
2.491.102
2.565.835
2.615.657
2.665.479
2.870.495
2.956.610
3.014.020
3.071.430
4.187.975
4.313.614
4.397.373
4.481.133
1.887.150
1.943.765
1.981.508
2.019.251
2.316.986
2.386.495
2.432.835
2.479.175
4.527.179
4.662.994
4.753.538
4.844.081
2.250.825
2.318.350
2.363.367
2.408.383
5.619.688
5.788.279
5.900.673
6.013.067
7.105.081
7.318.233
7.460.335
7.602.436
18.485.086
19.039.639
19.409.341
19.779.042
20.134.391
20.738.423
21.141.111
21.543.799
33.098.388
34.091.340
34.753.307
35.415.275
9.269.848
9.547.943
9.733.340
9.918.737
9.930.477
10.228.391
10.427.001
10.625.610
14.674.415
15.114.648
15.408.136
15.701.624
3.617.229
3.725.746
3.798.090
3.870.435
8.736.922
8.999.029
9.173.768
9.348.506
15.469.794
15.933.887
16.243.283
16.552.679
3.126.443
3.220.236
3.282.765
3.345.294
4.547.164
4.683.579
4.774.523
4.865.466
6.837.531
7.042.657
7.179.407
7.316.158
2.108.333
2.171.583
2.213.750
2.255.916
10.325.329
10.635.089
10.841.595
11.048.102
31.140.739
32.074.961
32.697.776
33.320.590

RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
Regional 1
319
I-4-23-i
320
I-4-23-ii
321
I-4-23-iii
322
I-4-24-i
323
I-4-24-ii
324
I-4-24-iii
325
J-1-01-i
326
J-1-01-ii
327
J-1-01-iii
328
J-1-02-i
329
J-1-02-ii
330
J-1-02-iii
331
J-1-10-i
332
J-1-10-ii
333
J-1-10-iii
334
J-1-20-i
335
J-1-20-ii
336
J-1-20-iii
337
J-1-30-i
338
J-1-30-ii
339
J-1-30-iii
340
J-4-10-i
2.433.298
2.506.297
2.554.963
2.603.629
341
J-4-10-ii
3.479.324
3.583.703
3.653.290
3.722.876
342
J-4-10-iii
5.263.697
5.421.608
5.526.882
5.632.156
343
J-4-11-i
1.535.101
1.581.154
1.611.857
1.642.559
344
J-4-11-ii
2.136.826
2.200.931
2.243.667
2.286.404
345
J-4-11-iii
3.062.126
3.153.990
3.215.233
3.276.475
- 533 No
Kode
INA-CBG
346
J-4-12-i
EMBOLI PARU RINGAN
347
J-4-12-ii
348
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
2.347.569
2.417.996
2.464.947
2.511.899
EMBOLI PARU SEDANG
3.040.021
3.131.222
3.192.022
3.252.823
J-4-12-iii
EMBOLI PARU BERAT
4.059.641
4.181.430
4.262.623
4.343.816
349
J-4-13-i
3.616.147
3.724.632
3.796.955
3.869.278
350
J-4-13-ii
5.315.737
5.475.209
5.581.523
5.687.838
351
J-4-13-iii
8.642.592
8.901.870
9.074.722
9.247.574
352
J-4-14-i
TUMOR PARU RINGAN
2.464.290
2.538.219
2.587.505
2.636.790
353
J-4-14-ii
TUMOR PARU SEDANG
4.128.023
4.251.864
4.334.424
4.416.985
354
J-4-14-iii
TUMOR PARU BERAT
4.908.010
5.055.250
5.153.410
5.251.571
2.299.479
2.368.463
2.414.453
2.460.442
4.161.244
4.286.081
4.369.306
4.452.531
5.199.391
5.355.373
5.459.361
5.563.348
1.916.232
1.973.719
2.012.044
2.050.369
2.682.725
2.763.207
2.816.862
2.870.516
4.839.354
4.984.535
5.081.322
5.178.109
2.393.078
2.464.870
2.512.732
2.560.593
3.233.459
3.330.463
3.395.132
3.459.802

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
Regional 1
355
J-4-15-i
356
J-4-15-ii
357
J-4-15-iii
358
J-4-16-i
359
J-4-16-ii
360
J-4-16-iii
361
J-4-17-i
362
J-4-17-ii
363
J-4-17-iii
4.227.460
4.354.283
4.438.833
4.523.382
364
J-4-18-i
2.153.093
2.217.686
2.260.748
2.303.809
365
J-4-18-ii
2.997.968
3.087.907
3.147.866
3.207.825
366
J-4-18-iii
3.109.555
3.202.842
3.265.033
3.327.224
367
J-4-19-i
2.682.725
2.763.207
2.816.862
2.870.516
368
J-4-19-ii
3.065.972
3.157.951
3.219.270
3.280.590
369
J-4-19-iii
4.803.204
4.947.300
5.043.365
5.139.429
2.682.725
2.763.207
2.816.862
2.870.516
3.272.429
3.370.602
3.436.051
3.501.499
7.394.510
7.616.345
7.764.236
7.912.126
1.532.986
1.578.975
1.609.635
1.640.295
3.782.156
3.895.621
3.971.264
4.046.907
5.394.592
5.556.429
5.664.321
5.772.213
4.130.132
4.254.036
4.336.638
4.419.241
5.763.870
5.936.786
6.052.063
6.167.341
6.750.484
6.952.999
7.088.008
7.223.018
370
J-4-20-i
371
J-4-20-ii
372
J-4-20-iii
373
J-4-21-i
374
J-4-21-ii
375
J-4-21-iii
376
K-1-10-i
377
K-1-10-ii
378
K-1-10-iii

RINGAN
SEDANG
USUS BESAR (RINGAN)
USUS BESAR (SEDANG)
USUS BESAR (BERAT)
- 534 No
Kode
INA-CBG
379
K-1-11-i
380
K-1-11-ii
381
K-1-11-iii
382
K-1-12-i
383
K-1-12-ii
384
K-1-12-iii
385
K-1-13-i
386
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
3.551.278
3.657.816
3.728.842
3.799.867
4.662.399
4.802.271
4.895.519
4.988.767
11.832.252
12.187.219
12.423.864
12.660.509
1.910.316
1.967.625
2.005.831
2.044.038
2.489.732
2.564.424
2.614.219
2.664.014
4.952.601
5.101.179
5.200.231
5.299.283
2.169.857
2.234.953
2.278.350
2.321.747
K-1-13-ii
3.790.117
3.903.820
3.979.622
4.055.425
387
K-1-13-iii
4.053.393
4.174.995
4.256.063
4.337.130
388
K-1-14-i
3.506.617
3.611.816
3.681.948
3.752.080
389
K-1-14-ii
4.118.919
4.242.487
4.324.865
4.407.243
390
K-1-14-iii
10.141.973
10.446.232
10.649.071
10.851.911
391
K-1-20-i
6.803.866
7.007.982
7.144.059
7.280.136
392
K-1-20-ii
9.496.402
9.781.294
9.971.222
10.161.150
393
K-1-20-iii
20.284.764
20.893.307
21.299.002
21.704.697
4.478.643
4.613.002
4.702.575
4.792.148
8.260.263
8.508.071
8.673.276
8.838.482
12.864.300
13.250.229
13.507.515
13.764.801
4.499.338
4.634.318
4.724.304
4.814.291
4.951.074
5.099.606
5.198.628
5.297.649
8.210.880
8.457.206
8.621.424
8.785.641

RINGAN
SEDANG
BERAT

FEMORAL RINGAN
FEMORAL SEDANG
FEMORAL BERAT

(RINGAN)
(SEDANG)
(BERAT)
Regional 1
394
K-1-30-i
395
K-1-30-ii
396
K-1-30-iii
397
K-1-40-i
398
K-1-40-ii
399
K-1-40-iii
400
K-1-50-i
3.431.909
3.534.866
3.603.504
3.672.143
401
K-1-50-ii
4.444.484
4.577.819
4.666.708
4.755.598
402
K-1-50-iii
PROSEDUR ANAL BERAT
6.309.985
6.499.285
6.625.485
6.751.684
403
K-4-10-i
2.599.424
2.677.407
2.729.395
2.781.384
404
K-4-10-ii
3.110.364
3.203.675
3.265.882
3.328.089
405
K-4-10-iii
12.879.976
13.266.375
13.523.975
13.781.574
406
K-4-11-i
1.532.986
1.578.975
1.609.635
1.640.295
407
K-4-11-ii
2.299.479
2.368.463
2.414.453
2.460.442
408
K-4-11-iii
4.178.982
4.304.351
4.387.931
4.471.510
409
K-4-12-i
1.532.986
1.578.975
1.609.635
1.640.295
410
K-4-12-ii
2.290.257
2.358.965
2.404.770
2.450.575
411
K-4-12-iii
5.496.454
5.661.348
5.771.277
5.881.206
- 535 No
Kode
INA-CBG
412
K-4-13-i
413
K-4-13-ii
414
K-4-13-iii
415
K-4-14-i
416
K-4-14-ii
417
K-4-14-iii
418
K-4-15-i
419
K-4-15-ii
420
K-4-15-iii
421
K-4-16-i
422
K-4-16-ii
423
K-4-16-iii
424
K-4-17-i
425
K-4-17-ii
426
K-4-17-iii
427
K-4-18-i
428
K-4-18-ii
429
K-4-18-iii
430
L-1-20-i
431
L-1-20-ii
432
L-1-20-iii
433
L-1-30-i
434
L-1-30-ii
435
L-1-30-iii
436
L-1-40-i
437
L-1-40-ii
438
L-1-40-iii
439
L-1-50-i
440
441
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
2.299.479
2.368.463
2.414.453
2.460.442
2.978.391
3.067.743
3.127.311
3.186.879
4.871.345
5.017.485
5.114.912
5.212.339
1.916.232
1.973.719
2.012.044
2.050.369
2.593.421
2.671.223
2.723.092
2.774.960
3.922.796
4.040.480
4.118.936
4.197.392
1.916.232
1.973.719
2.012.044
2.050.369
3.603.040
3.711.131
3.783.192
3.855.252
5.126.477
5.280.271
5.382.801
5.485.330
1.916.232
1.973.719
2.012.044
2.050.369
2.299.479
2.368.463
2.414.453
2.460.442
2.806.813
2.891.017
2.947.153
3.003.290
1.532.986
1.578.975
1.609.635
1.640.295
2.236.655
2.303.755
2.348.488
2.393.221
2.976.760
3.066.062
3.125.598
3.185.133
1.532.986
1.578.975
1.609.635
1.640.295
2.379.830
2.451.225
2.498.822
2.546.418
2.815.327
2.899.787
2.956.093
3.012.400
15.687.430
16.158.053
16.471.802
16.785.550
16.319.252
16.808.829
17.135.214
17.461.600
25.002.978
25.753.067
26.253.127
26.753.186
7.115.357
7.328.817
7.471.124
7.613.431
10.306.617
10.615.815
10.821.948
11.028.080
10.870.265
11.196.373
11.413.778
11.631.183
2.872.974
2.959.163
3.016.623
3.074.082
6.466.202
6.660.188
6.789.512
6.918.836
10.958.504
11.287.259
11.506.429
11.725.599
5.162.664
5.317.544
5.420.798
5.524.051
L-1-50-ii
9.292.796
9.571.580
9.757.436
9.943.292
L-1-50-iii
11.236.305
11.573.394
11.798.120
12.022.847

(RINGAN)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
(RINGAN)
(SEDANG)
(BERAT)
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
LUKA BAKAR RINGAN
LUKA BAKAR SEDANG
LUKA BAKAR BERAT
Regional 1
- 536 No
Kode
INA-CBG
442
L-4-10-i
443
L-4-10-ii
444
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
2.299.479
2.368.463
2.414.453
2.460.442
2.682.725
2.763.207
2.816.862
2.870.516
L-4-10-iii
5.426.924
5.589.732
5.698.270
5.806.809
445
L-4-11-i
2.174.888
2.240.135
2.283.633
2.327.130
446
L-4-11-ii
2.979.559
3.068.946
3.128.537
3.188.128
447
L-4-11-iii
8.080.191
8.322.597
8.484.200
8.645.804
448
L-4-12-i
2.299.479
2.368.463
2.414.453
2.460.442
449
L-4-12-ii
3.373.869
3.475.085
3.542.562
3.610.040
450
L-4-12-iii
5.657.579
5.827.306
5.940.458
6.053.610
1.443.313
1.486.613
1.515.479
1.544.345
1.664.226
1.714.152
1.747.437
1.780.721
2.496.468
2.571.362
2.621.292
2.671.221
1.532.986
1.578.975
1.609.635
1.640.295
2.299.479
2.368.463
2.414.453
2.460.442
3.595.277
3.703.135
3.775.040
3.846.946
7.473.904
7.698.121
7.847.599
7.997.077
8.342.085
8.592.348
8.759.190
8.926.031
11.718.370
12.069.921
12.304.288
12.538.656

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
Regional 1
451
L-4-13-i
452
L-4-13-ii
453
L-4-13-iii
454
L-4-14-i
455
L-4-14-ii
456
L-4-14-iii
457
M-1-01-i
458
M-1-01-ii
459
M-1-01-iii
460
M-1-02-i
5.293.430
5.452.233
5.558.101
5.663.970
461
M-1-02-ii
8.690.806
8.951.530
9.125.346
9.299.162
462
M-1-02-iii
15.738.650
16.210.810
16.525.583
16.840.356
463
M-1-03-i
13.422.928
13.825.615
14.094.074
14.362.533
464
M-1-03-ii
15.708.751
16.180.013
16.494.188
16.808.363
465
M-1-03-iii
16.004.260
16.484.388
16.804.473
17.124.558
466
M-1-04-i
3.491.917
3.596.675
3.666.513
3.736.351
467
M-1-04-ii
4.476.601
4.610.899
4.700.432
4.789.964
468
M-1-04-iii
5.601.623
5.769.672
5.881.704
5.993.736
469
M-1-05-i
5.439.736
5.602.928
5.711.723
5.820.518
470
M-1-05-ii
6.286.877
6.475.484
6.601.221
6.726.959
471
M-1-05-iii
10.708.264
11.029.512
11.243.678
11.457.843
472
M-1-07-i
6.004.707
6.184.849
6.304.943
6.425.037

PROSEDUR PADA SENDI
BAWAH MAYOR (RINGAN)
PROSEDUR PADA SENDI
BAWAH MAYOR (SEDANG)
PROSEDUR PADA SENDI
BAWAH MAYOR (BERAT)
- 537 No
Kode
INA-CBG
473
M-1-07-ii
474
M-1-07-iii
475
M-1-10-i
476
M-1-10-ii
477
M-1-10-iii
478
M-1-20-i
479
M-1-20-ii
480
M-1-20-iii
481
M-1-30-i
482
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
8.044.431
8.285.764
8.446.653
8.607.542
16.387.270
16.878.888
17.206.633
17.534.378
3.752.827
3.865.411
3.940.468
4.015.525
13.940.051
14.358.252
14.637.053
14.915.854
17.051.339
17.562.879
17.903.906
18.244.933
3.712.515
3.823.891
3.898.141
3.972.391
5.299.282
5.458.261
5.564.246
5.670.232
10.300.649
10.609.669
10.815.682
11.021.695
2.220.639
2.287.258
2.331.671
2.376.084
M-1-30-ii
4.588.405
4.726.057
4.817.825
4.909.594
483
M-1-30-iii
PROSEDUR KAKI BERAT
6.844.933
7.050.281
7.187.180
7.324.078
484
M-1-40-i
2.243.783
2.311.097
2.355.972
2.400.848
485
M-1-40-ii
4.130.132
4.254.036
4.336.638
4.419.241
486
M-1-40-iii
7.227.730
7.444.562
7.589.117
7.733.671
487
M-1-50-i
2.971.608
3.060.756
3.120.189
3.179.621
488
M-1-50-ii
5.981.917
6.161.375
6.281.013
6.400.651
489
M-1-50-iii
8.260.263
8.508.071
8.673.276
8.838.482
2.242.626
2.309.905
2.354.758
2.399.610
4.489.753
4.624.445
4.714.240
4.804.036
7.813.758
8.048.171
8.204.446
8.360.721
3.004.218
3.094.344
3.154.429
3.214.513
6.130.092
6.313.995
6.436.597
6.559.199
9.882.449
10.178.922
10.376.571
10.574.220

LENGKUNGAN TULANG BELAKANG
SEDANG
TULANG WAJAH RINGAN
TULANG WAJAH SEDANG
TULANG WAJAH BERAT

RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
SELAIN KAKI (BERAT)
Regional 1
490
M-1-60-i
491
M-1-60-ii
492
M-1-60-iii
493
M-1-70-i
494
M-1-70-ii
495
M-1-70-iii
496
M-1-80-i
2.420.586
2.493.204
2.541.616
2.590.028
497
M-1-80-ii
3.659.432
3.769.215
3.842.403
3.915.592
498
M-1-80-iii
8.424.960
8.677.709
8.846.208
9.014.707
499
M-4-10-i
1.532.986
1.578.975
1.609.635
1.640.295
500
M-4-10-ii
2.338.952
2.409.120
2.455.899
2.502.678
501
M-4-10-iii
FRAKTUR FEMUR BERAT
4.966.640
5.115.639
5.214.972
5.314.305
- 538 No
Kode
INA-CBG
502
M-4-11-i
503
M-4-11-ii
504
M-4-11-iii
505
M-4-12-i
506
M-4-12-ii
507
M-4-12-iii
508
M-4-13-i
509
M-4-13-ii
510
M-4-13-iii
511
M-4-14-i
512
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
2.028.829
2.089.694
2.130.270
2.170.847
4.654.436
4.794.069
4.887.157
4.980.246
8.261.514
8.509.360
8.674.590
8.839.820
1.532.986
1.578.975
1.609.635
1.640.295
2.789.266
2.872.944
2.928.729
2.984.515
5.586.170
5.753.755
5.865.479
5.977.202
2.830.027
2.914.928
2.971.529
3.028.129
3.832.465
3.947.439
4.024.088
4.100.737
8.418.622
8.671.181
8.839.554
9.007.926
3.065.972
3.157.951
3.219.270
3.280.590
M-4-14-ii
3.980.453
4.099.867
4.179.476
4.259.085
513
M-4-14-iii
OSTEOMIELITIS BERAT
5.962.290
6.141.159
6.260.405
6.379.651
514
M-4-15-i
1.912.838
1.970.224
2.008.480
2.046.737
515
M-4-15-ii
2.550.612
2.627.131
2.678.143
2.729.155
516
M-4-15-iii
6.515.190
6.710.646
6.840.950
6.971.253
517
M-4-16-i
1.916.232
1.973.719
2.012.044
2.050.369
518
M-4-16-ii
3.065.972
3.157.951
3.219.270
3.280.590
519
M-4-16-iii
5.700.955
5.871.984
5.986.003
6.100.022
520
M-4-17-i
1.916.232
1.973.719
2.012.044
2.050.369
521
M-4-17-ii
2.682.725
2.763.207
2.816.862
2.870.516
522
M-4-17-iii
3.746.568
3.858.965
3.933.897
4.008.828
523
M-4-18-i
2.246.122
2.313.506
2.358.428
2.403.350
524
M-4-18-ii
3.065.972
3.157.951
3.219.270
3.280.590
525
M-4-18-iii
3.809.292
3.923.570
3.999.756
4.075.942
526
M-4-19-i
1.670.022
1.720.123
1.753.523
1.786.924
527
M-4-19-ii
2.812.852
2.897.238
2.953.495
3.009.752
528
M-4-19-iii
5.493.708
5.658.519
5.768.394
5.878.268
529
M-4-20-i
1.532.986
1.578.975
1.609.635
1.640.295
530
M-4-20-ii
2.299.479
2.368.463
2.414.453
2.460.442

PANGGUL RINGAN
PANGGUL SEDANG
PANGGUL BERAT
PELVIS RINGAN
PELVIS SEDANG
PELVIS BERAT
RINGAN
SEDANG

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
RINGAN
SEDANG
BERAT
ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
(RINGAN)
(SEDANG)
Regional 1
- 539 No
Kode
INA-CBG
531
M-4-20-iii
532
M-4-21-i
533
M-4-21-ii
534
M-4-21-iii
535
N-1-01-i
536
N-1-01-ii
537
N-1-01-iii
538
N-1-11-i
539
N-1-11-ii
540
N-1-11-iii
541
N-1-12-i
542
N-1-12-ii
543
N-1-12-iii
544
N-1-20-i
545
N-1-20-ii
546
N-1-20-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
2.548.365
2.624.815
2.675.783
2.726.750
1.532.986
1.578.975
1.609.635
1.640.295
2.000.932
2.060.960
2.100.979
2.140.997
4.877.428
5.023.751
5.121.299
5.218.848
4.147.845
4.272.281
4.355.237
4.438.194
5.609.867
5.778.163
5.890.360
6.002.558
11.894.587
12.251.424
12.489.316
12.727.208
5.722.273
5.893.941
6.008.386
6.122.832
7.739.245
7.971.422
8.126.207
8.280.992
16.409.501
16.901.786
17.229.976
17.558.166
3.097.599
3.190.527
3.252.479
3.314.431
7.206.344
7.422.534
7.566.661
7.710.788
13.134.011
13.528.031
13.790.712
14.053.392
4.193.904
4.319.721
4.403.599
4.487.477
8.315.021
8.564.471
8.730.772
8.897.072
9.511.630
9.796.979
9.987.211
10.177.444
4.989.389
5.139.071
5.238.858
5.338.646
7.581.999
7.809.459
7.961.099
8.112.739
8.728.131
8.989.975
9.164.538
9.339.100
4.495.928
4.630.806
4.720.724
4.810.643
6.094.391
6.277.222
6.399.110
6.520.998
7.087.952
7.300.591
7.442.350
7.584.109
1.916.232
1.973.719
2.012.044
2.050.369
2.565.889
2.642.865
2.694.183
2.745.501
5.616.269
5.784.757
5.897.082
6.009.407

(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
RINGAN
SEDANG
RINGAN
SEDANG
BERAT

URIN BAWAH RINGAN
URIN BAWAH SEDANG
URIN BAWAH BERAT
TRANSURETRA RINGAN
TRANSURETRA SEDANG
TRANSURETRA BERAT
GINJAL RINGAN
GINJAL SEDANG
GINJAL BERAT
Regional 1
547
N-1-30-i
548
N-1-30-ii
549
N-1-30-iii
550
N-1-40-i
551
N-1-40-ii
552
N-1-40-iii
553
N-4-10-i
554
N-4-10-ii
555
N-4-10-iii
556
N-4-11-i
1.467.457
1.511.480
1.540.830
1.570.179
557
N-4-11-ii
2.479.967
2.554.366
2.603.965
2.653.564
558
N-4-11-iii
2.874.349
2.960.579
3.018.066
3.075.553
559
N-4-12-i
1.532.986
1.578.975
1.609.635
1.640.295
560
N-4-12-ii
2.299.479
2.368.463
2.414.453
2.460.442

RINGAN
SEDANG
- 540 No
Kode
INA-CBG
561
N-4-12-iii
562
N-4-13-i
563
N-4-13-ii
564
N-4-13-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
3.817.891
3.932.427
4.008.785
4.085.143
BATU URIN RINGAN
2.022.480
2.083.154
2.123.604
2.164.053
BATU URIN SEDANG
2.438.350
2.511.500
2.560.267
2.609.034
BATU URIN BERAT
6.004.987
6.185.137
6.305.236
6.425.336
1.327.850
1.367.685
1.394.242
1.420.799
2.044.722
2.106.064
2.146.958
2.187.852
3.315.887
3.415.364
3.481.681
3.547.999
1.969.969
2.029.068
2.068.467
2.107.867
2.703.410
2.784.513
2.838.581
2.892.649
3.085.079
3.177.631
3.239.333
3.301.035
2.556.747
2.633.450
2.684.585
2.735.720
3.065.972
3.157.951
3.219.270
3.280.590
6.447.283
6.640.701
6.769.647
6.898.592
3.775.164
3.888.419
3.963.922
4.039.425
4.191.007
4.316.737
4.400.558
4.484.378
4.698.169
4.839.114
4.933.078
5.027.041
1.973.036
2.032.227
2.071.687
2.111.148
2.531.225
2.607.161
2.657.786
2.708.410
4.289.640
4.418.329
4.504.122
4.589.915
1.718.129
1.769.672
1.804.035
1.838.398
2.063.468
2.125.372
2.166.642
2.207.911
2.592.452
2.670.226
2.722.075
2.773.924

(RINGAN)
(SEDANG)
(BERAT)
SALURAN URIN RINGAN
SALURAN URIN SEDANG
SALURAN URIN BERAT
LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
RINGAN
SEDANG
BERAT
&KURET RINGAN
& KURET SEDANG
& KURET BERAT
Regional 1
565
N-4-14-i
566
N-4-14-ii
567
N-4-14-iii
568
N-4-15-i
569
N-4-15-ii
570
N-4-15-iii
571
N-4-16-i
572
N-4-16-ii
573
N-4-16-iii
574
O-6-10-i
575
O-6-10-ii
576
O-6-10-iii
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
1.721.875
1.773.531
1.807.968
1.842.406
584
O-6-13-ii
2.537.705
2.613.836
2.664.590
2.715.345
585
O-6-13-iii
2.999.176
3.089.151
3.149.135
3.209.118
38.517.557
39.673.083
40.443.434
41.213.786
47.659.451
49.089.235
50.042.424
50.995.613
586
P-8-01-i
587
P-8-01-ii

- 541 No
Kode
INA-CBG
588
P-8-01-iii
589
P-8-02-i
590
P-8-02-ii
591
P-8-02-iii
592
P-8-03-i
593
P-8-03-ii
594
P-8-03-iii
595
P-8-04-i
596
P-8-04-ii
597
P-8-04-iii
598
P-8-05-i
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii
603
P-8-06-iii
604
P-8-07-i
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
Deskripsi (INA-CBG)
RINGAN
SEDANG
RINGAN
SEDANG
RINGAN
SEDANG
RINGAN
SEDANG
RINGAN
SEDANG
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
LAIN RINGAN
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
55.938.835
57.617.001
58.735.777
59.854.554
46.667.026
48.067.037
49.000.377
49.933.718
53.531.882
55.137.839
56.208.476
57.279.114
61.164.003
62.998.923
64.222.203
65.445.483
2.581.332
2.658.772
2.710.399
2.762.025
3.613.865
3.722.281
3.794.558
3.866.836
5.692.657
5.863.437
5.977.290
6.091.143
23.053.110
23.744.703
24.205.765
24.666.828
29.917.966
30.815.505
31.413.865
32.012.224
42.894.833
44.181.678
45.039.575
45.897.471
12.535.534
12.911.600
13.162.310
13.413.021
17.767.429
18.300.452
18.655.801
19.011.149
26.177.922
26.963.259
27.486.818
28.010.376
2.065.066
2.127.018
2.168.319
2.209.620
5.196.247
5.352.134
5.456.059
5.559.984
9.665.611
9.955.580
10.148.892
10.342.204
3.613.865
3.722.281
3.794.558
3.866.836
10.132.408
10.436.380
10.639.028
10.841.676
13.422.928
13.825.615
14.094.074
14.362.533
2.618.902
2.697.469
2.749.847
2.802.225
3.717.900
3.829.437
3.903.795
3.978.153
5.248.533
5.405.989
5.510.960
5.615.931
1.624.764
1.673.507
1.706.002
1.738.497
- 542 No
Kode
INA-CBG
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
614
P-8-11-ii
615
P-8-11-iii
616
P-8-12-i
617
P-8-12-ii
618
P-8-12-iii
619
P-8-13-i
620
P-8-13-ii
621
P-8-13-iii
622
P-8-14-i
623
P-8-14-ii
624
P-8-14-iii
625
P-8-15-i
626
P-8-15-ii
627
P-8-15-iii
628
P-8-16-i
629
P-8-16-ii
630
P-8-16-iii
631
P-8-17-i
632
P-8-17-ii
633
P-8-17-iii
634
S-4-10-i
635
S-4-10-ii
636
S-4-10-iii
637
S-4-11-i
638
639
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
2.353.707
2.424.318
2.471.392
2.518.467
4.621.021
4.759.651
4.852.072
4.944.492
4.576.026
4.713.307
4.804.827
4.896.348
9.742.233
10.034.500
10.229.345
10.424.190
9.946.335
10.244.725
10.443.652
10.642.578
2.158.849
2.223.614
2.266.791
2.309.968
3.356.635
3.457.334
3.524.467
3.591.600
3.960.120
4.078.923
4.158.126
4.237.328
1.115.809
1.149.284
1.171.600
1.193.916
2.064.797
2.126.741
2.168.037
2.209.332
3.088.124
3.180.768
3.242.530
3.304.293
2.038.700
2.099.861
2.140.635
2.181.409
4.162.448
4.287.322
4.370.571
4.453.820
4.566.190
4.703.176
4.794.500
4.885.824
1.533.166
1.579.161
1.609.824
1.640.488
3.064.396
3.156.327
3.217.615
3.278.903
3.599.607
3.707.595
3.779.587
3.851.580
1.387.878
1.429.514
1.457.271
1.485.029
1.968.764
2.027.826
2.067.202
2.106.577
2.555.552
2.632.218
2.683.329
2.734.441
915.996
943.476
961.796
980.116
3.042.629
3.133.908
3.194.761
3.255.613
6.141.353
6.325.594
6.448.421
6.571.248
1.532.986
1.578.975
1.609.635
1.640.295
1.916.232
1.973.719
2.012.044
2.050.369
2.490.773
2.565.496
2.615.312
2.665.127
958.116
986.860
1.006.022
1.025.184
S-4-11-ii
1.458.271
1.502.019
1.531.184
1.560.350
S-4-11-iii
2.359.227
2.430.004
2.477.189
2.524.373

LAIN SEDANG
LAIN BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
HEREDITER RINGAN
HEREDITER SEDANG
HEREDITER BERAT
SINDROMA ASPIRASI RINGAN
SINDROMA ASPIRASI SEDANG
SINDROMA ASPIRASI BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
Regional 1
- 543 No
Kode
INA-CBG
640
S-4-12-i
641
S-4-12-ii
642
S-4-12-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
PASIEN RINGAN
PASIEN SEDANG
PASIEN BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.149.739
1.184.232
1.207.226
1.230.221
1.532.986
1.578.975
1.609.635
1.640.295
2.994.043
3.083.864
3.143.745
3.203.626
1.532.986
1.578.975
1.609.635
1.640.295
2.709.975
2.791.275
2.845.474
2.899.674
5.517.854
5.683.390
5.793.747
5.904.104
934.020
962.041
980.721
999.402
1.984.172
2.043.697
2.083.381
2.123.064
3.762.697
3.875.578
3.950.832
4.026.086
706.408
727.600
741.728
755.857
1.333.233
1.373.230
1.399.894
1.426.559
1.726.846
1.778.651
1.813.188
1.847.725
643
S-4-13-i
644
S-4-13-ii
645
S-4-13-iii
646
S-4-14-i
647
S-4-14-ii
648
S-4-14-iii
649
S-4-15-i
650
S-4-15-ii
651
S-4-15-iii
652
S-4-16-i
LUKA BAKAR RINGAN
2.682.725
2.763.207
2.816.862
2.870.516
653
S-4-16-ii
LUKA BAKAR SEDANG
3.788.882
3.902.549
3.978.326
4.054.104
654
S-4-16-iii
LUKA BAKAR BERAT
6.765.637
6.968.606
7.103.919
7.239.232
1.430.482
1.473.396
1.502.006
1.530.615
1.916.232
1.973.719
2.012.044
2.050.369
3.124.795
3.218.539
3.281.035
3.343.531
1.476.652
1.520.952
1.550.485
1.580.018
1.983.043
2.042.535
2.082.196
2.121.856
3.607.802
3.716.036
3.788.193
3.860.349
645.930
665.308
678.226
691.145
1.230.999
1.267.929
1.292.549
1.317.169
1.789.538
1.843.224
1.879.015
1.914.806
638.787
657.951
670.727
683.503
1.005.270
1.035.428
1.055.533
1.075.639
1.619.193
1.667.769
1.700.153
1.732.537
1.341.363
1.381.604
1.408.431
1.435.258
2.027.396
2.088.218
2.128.766
2.169.314
3.153.899
3.248.516
3.311.594
3.374.672
655
S-4-17-i
656
S-4-17-ii
657
S-4-17-iii
658
T-1-10-i
659
T-1-10-ii
660
T-1-10-iii
661
T-4-10-i
662
T-4-10-ii
663
T-4-10-iii
664
T-4-11-i
665
T-4-11-ii
666
T-4-11-iii
667
T-4-12-i
668
T-4-12-ii
669
T-4-12-iii

DAN EFEK TOKSIK LAIN-LAIN RINGAN
DAN EFEK TOKSIK LAIN-LAIN SEDANG
DAN EFEK TOKSIK LAIN-LAIN BERAT
DOKTER RINGAN
DOKTER SEDANG
DOKTER BERAT
- 544 No
Kode
INA-CBG
670
U-1-10-i
671
U-1-10-ii
672
U-1-10-iii
673
U-1-11-i
674
U-1-11-ii
675
U-1-11-iii
676
U-1-12-i
677
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
1.427.758
1.470.590
1.499.146
1.527.701
2.913.427
3.000.830
3.059.099
3.117.367
12.580.768
12.958.191
13.209.806
13.461.421
6.195.197
6.381.053
6.504.957
6.628.861
8.260.263
8.508.071
8.673.276
8.838.482
13.877.977
14.294.317
14.571.876
14.849.436
3.785.952
3.899.531
3.975.250
4.050.969
U-1-12-ii
9.292.796
9.571.580
9.757.436
9.943.292
678
U-1-12-iii
12.066.872
12.428.878
12.670.215
12.911.553
679
U-1-13-i
4.130.132
4.254.036
4.336.638
4.419.241
680
U-1-13-ii
4.659.909
4.799.706
4.892.904
4.986.103
681
U-1-13-iii
8.985.619
9.255.187
9.434.900
9.614.612
682
U-1-14-i
2.278.877
2.347.243
2.392.821
2.438.398
683
U-1-14-ii
2.796.640
2.880.539
2.936.472
2.992.405
684
U-1-14-iii
3.314.097
3.413.520
3.479.802
3.546.084
685
U-1-15-i
1.338.471
1.378.625
1.405.395
1.432.164
686
U-1-15-ii
1.901.874
1.958.930
1.996.968
2.035.005
687
U-1-15-iii
3.747.719
3.860.151
3.935.105
4.010.060
688
U-1-20-i
3.462.042
3.565.903
3.635.144
3.704.385
689
U-1-20-ii
6.162.435
6.347.308
6.470.557
6.593.805
690
U-1-20-iii
15.202.952
15.659.040
15.963.099
16.267.158
691
U-1-30-i
2.969.828
3.058.923
3.118.320
3.177.716
692
U-1-30-ii
4.009.268
4.129.546
4.209.732
4.289.917
693
U-1-30-iii
7.859.319
8.095.098
8.252.284
8.409.471
694
U-4-10-i
2.764.414
2.847.347
2.902.635
2.957.923
695
U-4-10-ii
6.929.806
7.137.700
7.276.296
7.414.892
696
U-4-10-iii
10.109.077
10.412.350
10.614.531
10.816.713
697
U-4-11-i
1.532.986
1.578.975
1.609.635
1.640.295
698
U-4-11-ii
2.299.479
2.368.463
2.414.453
2.460.442
699
U-4-11-iii
3.180.170
3.275.575
3.339.179
3.402.782
700
U-4-12-i
1.532.986
1.578.975
1.609.635
1.640.295
701
U-4-12-ii
1.787.108
1.840.722
1.876.464
1.912.206
702
U-4-12-iii
2.841.421
2.926.664
2.983.492
3.040.321

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)

LANGIT-LANGIT MULUT (RINGAN)
LANGIT-LANGIT MULUT (SEDANG)
LANGIT-LANGIT MULUT (BERAT)

HIDUNG DAN TELINGA LAIN-LAIN (RINGAN)
HIDUNG DAN TELINGA LAIN-LAIN (SEDANG)
HIDUNG DAN TELINGA LAIN-LAIN (BERAT)

DAN TELINGA RINGAN
DAN TELINGA SEDANG
DAN TELINGA BERAT
Regional 1
- 545 No
Kode
INA-CBG
703
U-4-13-i
704
U-4-13-ii
705
U-4-13-iii
706
U-4-14-i
707
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
1.506.046
1.551.227
1.581.348
1.611.469
1.750.866
1.803.392
1.838.409
1.873.427
1.987.980
2.047.620
2.087.379
2.127.139
1.916.232
1.973.719
2.012.044
2.050.369
U-4-14-ii
2.299.479
2.368.463
2.414.453
2.460.442
708
U-4-14-iii
3.852.026
3.967.587
4.044.627
4.121.668
709
U-4-15-i
1.532.986
1.578.975
1.609.635
1.640.295
710
U-4-15-ii
1.916.232
1.973.719
2.012.044
2.050.369
711
U-4-15-iii
2.683.245
2.763.743
2.817.408
2.871.073
712
V-1-10-i
4.481.426
4.615.869
4.705.497
4.795.126
713
V-1-10-ii
5.162.664
5.317.544
5.420.798
5.524.051
714
V-1-10-iii
9.809.062
10.103.334
10.299.516
10.495.697
715
V-1-11-i
5.162.664
5.317.544
5.420.798
5.524.051
716
V-1-11-ii
5.761.620
5.934.469
6.049.701
6.164.934
717
V-1-11-iii
8.532.077
8.788.040
8.958.681
9.129.323
2.788.254
2.871.902
2.927.667
2.983.432
10.655.780
10.975.453
11.188.569
11.401.685
12.441.594
12.814.842
13.063.674
13.312.506
4.226.089
4.352.872
4.437.394
4.521.916
8.030.782
8.271.706
8.432.321
8.592.937
12.390.395
12.762.107
13.009.914
13.257.722
5.094.600
5.247.438
5.349.330
5.451.222
7.409.659
7.631.949
7.780.142
7.928.335
10.072.353
10.374.524
10.575.971
10.777.418


HIDUNG & TELINGA LAIN-LAIN (RINGAN)
HIDUNG & TELINGA LAIN-LAIN (SEDANG)
HIDUNG & TELINGA LAIN-LAIN (BERAT)
KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

NON KOMPLEK (BERAT)
Regional 1
718
V-1-12-i
719
V-1-12-ii
720
V-1-12-iii
721
V-1-13-i
722
V-1-13-ii
723
V-1-13-iii
724
V-1-14-i
725
V-1-14-ii
726
V-1-14-iii
727
V-1-15-i
2.401.820
2.473.875
2.521.911
2.569.948
728
V-1-15-ii
4.575.000
4.712.250
4.803.750
4.895.250
729
V-1-15-iii
8.042.762
8.284.045
8.444.900
8.605.756
730
V-4-10-i
3.867.537
3.983.563
4.060.914
4.138.264
731
V-4-10-ii
4.995.386
5.145.247
5.245.155
5.345.063
732
V-4-10-iii
9.547.059
9.833.470
10.024.412
10.215.353
733
V-4-11-i
1.966.787
2.025.791
2.065.127
2.104.462
734
V-4-11-ii
2.873.790
2.960.004
3.017.480
3.074.956
TUMOR PADA SISTEM REPRODUKSI LAKILAKI RINGAN

TUMOR PADA SISTEM REPRODUKSI LAKILAKI SEDANG
TUMOR PADA SISTEM REPRODUKSI LAKILAKI BERAT
- 546 No
Kode
INA-CBG
735
V-4-11-iii
736
W-1-01-i
737
W-1-01-ii
738
W-1-01-iii
739
W-1-10-i
740
W-1-10-ii
741
W-1-10-iii
742
W-1-11-i
743
W-1-11-ii
744
W-1-11-iii
745
W-1-12-i
746
W-1-12-ii
747
W-1-12-iii
748
W-1-13-i
749
W-1-13-ii
750
W-1-13-iii
751
W-1-20-i
752
W-1-20-ii
753
W-1-20-iii
754
W-1-30-i
755
W-1-30-ii
756
W-1-30-iii
757
W-4-10-i
758
W-4-10-ii
759
W-4-10-iii
760
W-4-11-i
761
W-4-11-ii
762
W-4-11-iii
763
W-4-12-i
764
W-4-12-ii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
4.741.564
4.883.811
4.978.642
5.073.473
5.783.318
5.956.817
6.072.484
6.188.150
6.965.732
7.174.704
7.314.018
7.453.333
15.385.918
15.847.495
16.155.214
16.462.932
1.610.647
1.658.966
1.691.179
1.723.392
3.005.732
3.095.904
3.156.018
3.216.133
4.916.423
5.063.916
5.162.244
5.260.573
1.672.927
1.723.114
1.756.573
1.790.031
3.226.451
3.323.244
3.387.773
3.452.302
6.195.197
6.381.053
6.504.957
6.628.861
1.520.105
1.565.708
1.596.111
1.626.513
1.728.331
1.780.180
1.814.747
1.849.314
2.654.934
2.734.582
2.787.680
2.840.779
1.809.285
1.863.563
1.899.749
1.935.934
1.964.362
2.023.292
2.062.580
2.101.867
2.638.500
2.717.655
2.770.425
2.823.195
4.929.785
5.077.678
5.176.274
5.274.870
6.934.482
7.142.517
7.281.206
7.419.896
8.760.206
9.023.012
9.198.216
9.373.420
2.691.168
2.771.903
2.825.727
2.879.550

RINGAN
SEDANG
BERAT

& SERVIK RINGAN
& SERVIK SEDANG
& SERVIK BERAT
ENDOSKOP RINGAN
ENDOSKOP SEDANG
ENDOSKOP BERAT
RINGAN
SEDANG
Regional 1

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
4.292.553
4.421.329
4.507.180
4.593.031
11.414.953
11.757.402
11.985.701
12.214.000
2.006.937
2.067.145
2.107.284
2.147.423
2.712.601
2.793.979
2.848.231
2.902.483
6.131.944
6.315.902
6.438.541
6.561.180
1.916.232
1.973.719
2.012.044
2.050.369
3.065.972
3.157.951
3.219.270
3.280.590
3.726.064
3.837.846
3.912.368
3.986.889
1.532.986
1.578.975
1.609.635
1.640.295
2.107.856
2.171.091
2.213.248
2.255.406

RINGAN
SEDANG
- 547 No
Kode
INA-CBG
765
W-4-12-iii

766
W-4-13-i
767
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 2
Regional 3
Regional 4
2.350.025
2.420.526
2.467.526
2.514.527
ABORTUS RINGAN
840.708
865.929
882.743
899.557
W-4-13-ii
ABORTUS SEDANG
1.149.739
1.184.232
1.207.226
1.230.221
768
W-4-13-iii
ABORTUS BERAT
1.532.986
1.578.975
1.609.635
1.640.295
769
W-4-14-i
1.149.739
1.184.232
1.207.226
1.230.221
770
W-4-14-ii
1.478.751
1.523.113
1.552.688
1.582.263
771
W-4-14-iii
1.860.721
1.916.542
1.953.757
1.990.971
772
W-4-15-i
958.749
987.511
1.006.686
1.025.861
773
W-4-15-ii
1.066.311
1.098.301
1.119.627
1.140.953
774
W-4-15-iii
1.476.409
1.520.702
1.550.230
1.579.758
775
W-4-16-i
1.149.739
1.184.232
1.207.226
1.230.221
776
W-4-16-ii
1.532.986
1.578.975
1.609.635
1.640.295
777
W-4-16-iii
2.090.018
2.152.718
2.194.519
2.236.319
778
W-4-17-i
939.056
967.228
986.009
1.004.790
779
W-4-17-ii
1.532.986
1.578.975
1.609.635
1.640.295
780
W-4-17-iii
2.900.104
2.987.108
3.045.110
3.103.112
781
Z-4-10-i
REHABILITASI RINGAN
2.630.422
2.709.335
2.761.943
2.814.552
782
Z-4-10-ii
REHABILITASI SEDANG
3.491.506
3.596.251
3.666.081
3.735.911
783
Z-4-10-iii
REHABILITASI BERAT
4.960.017
5.108.818
5.208.018
5.307.218
784
Z-4-11-i
2.296.069
2.364.951
2.410.873
2.456.794
785
Z-4-11-ii
2.763.960
2.846.879
2.902.158
2.957.437
786
Z-4-11-iii
4.373.076
4.504.268
4.591.730
4.679.191
787
Z-4-12-i
1.447.148
1.490.563
1.519.506
1.548.449
788
Z-4-12-ii
2.948.517
3.036.973
3.095.943
3.154.913
789
Z-4-12-iii
3.747.098
3.859.511
3.934.453
4.009.395

RINGAN
SEDANG
Regional 1
- 548 b. RawatJalan
No
Kode
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
775.006
798.256
813.756
829.256
1.005.304
1.035.463
1.055.569
1.075.675
1.869.494
1.925.579
1.962.969
2.000.359
1.544.956
1.591.304
1.622.204
1.653.103
1.290.677
1.329.398
1.355.211
1.381.025
452.517
466.093
475.143
484.193
1.009.054
1.039.326
1.059.507
1.079.688

207.327
213.547
217.694
221.840
C-3-10-0
565.560
582.527
593.838
605.149
10
C-3-11-0

KANDUNG KEMIH
894.454
921.288
939.177
957.066
11
C-3-12-0
202.771
208.854
212.909
216.965
196.904
202.812
206.750
210.688
1.676.251
1.726.538
1.760.063
1.793.588
1.536.351
1.582.441
1.613.168
1.643.895

LAPAROSKOPI
& PANKREAS
LAPAROSKOPI
SALURAN EMPEDU
KEMOTERAPI PADA TUMOR PAYUDARA

ATAU OVARIUM
GASTROINTESTINAL
GINJAL ATAU PROSTAT
12
C-3-13-0
13
C-3-14-0
14
C-3-15-0
15
C-3-16-0
348.407
358.860
365.828
372.796
16
C-3-17-0

LEHER
231.123
238.057
242.679
247.302
17
C-3-18-0
102.470
105.544
107.594
109.643
18
C-3-19-0

MYELOMA ATAU TESTIS
144.913
149.261
152.159
155.057
19
C-3-20-0
2.885.957
2.972.536
3.030.255
3.087.974
20
C-3-21-0
165.372
170.333
173.641
176.948
21
C-3-22-0
726.072
747.854
762.376
776.897
22
C-3-23-0
117.608
121.136
123.488
125.840
23
D-2-10-0

TULANG
996.390
1.026.282
1.046.209
1.066.137
24
D-2-11-0
PROSEDUR LIMPA
1.247.650
1.285.080
1.310.033
1.334.986
25
D-2-21-0
1.046.425
1.077.818
1.098.747
1.119.675
26
D-2-22-0
229.659
236.549
241.142
245.735
27
D-3-10-0
166.348
171.338
174.665
177.992
28
D-3-11-0
431.886
444.843
453.481
462.118
29
E-2-10-0
256.192
263.877
269.001
274.125
30
E-2-21-0
185.730
191.302
195.017
198.731
31
E-2-22-0
185.730
191.302
195.017
198.731

TYMUS
TYMUS
TULANG
PROSEDUR DIAGNOSTIK DARAH DAN
ORGAN PEMBENTUK DARAH
DAN PARATIROID
THYROGLOSSAL
- 549 No
Kode
INA-CBG
32
E-3-10-0
33
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

ENDOKRIN
215.992
222.472
226.792
231.112
F-3-10-0
TERAPI SHOCK
301.302
310.341
316.367
322.393
34
F-5-10-0
PELAYANAN KESEHATAN MENTAL

EKSTENSIF
369.193
380.268
387.652
395.036
35
F-5-11-0
TERAPI KELOMPOK
243.449
250.752
255.621
260.490
36
F-5-12-0
PROSEDUR TES DIAGNOSTIK KESEHATAN

JIWA
311.534
320.880
327.110
333.341
37
F-5-13-0
263.848
271.764
277.041
282.318
38
F-5-14-0
177.007
182.317
185.857
189.397
39
F-5-15-0
166.055
171.037
174.358
177.679
40
F-5-16-0
172.963
178.151
181.611
185.070
41
G-2-10-0
145.648
150.017
152.930
155.843
42
G-2-11-0
1.262.536
1.300.412
1.325.663
1.350.914
43
G-2-12-0

EKSTRAKRANIAL
1.829.726
1.884.618
1.921.212
1.957.807
44
G-2-13-0
448.873
462.339
471.316
480.294
45
G-2-21-0
818.668
843.228
859.601
875.975
46
G-2-22-0
743.011
765.301
780.161
795.022
47
G-2-31-0
1.226.033
1.262.814
1.287.334
1.311.855
48
G-2-32-0
628.463
647.317
659.886
672.456
49
G-3-10-0
249.441
256.924
261.913
266.902
50
G-3-11-0
332.208
342.174
348.818
355.462
51
G-3-12-0
PROSEDUR PEMERIKSAAN NEUROLOGIS

LAIN
544.328
560.658
571.544
582.431
52
G-3-13-0
544.390
560.722
571.610
582.497
53
H-2-21-0
737.625
759.754
774.506
789.259
54
H-2-22-0
191.760
197.513
201.348
205.183
55
H-2-23-0
191.760
197.513
201.348
205.183
1.221.814
1.258.469
1.282.905
1.307.341
127.162
130.977
133.520
136.064
191.760
197.513
201.348
205.183
548.136
564.580
575.542
586.505
180.623
186.042
189.654
193.267
974.961
1.004.210
1.023.710
1.043.209
1.037.889
1.069.026
1.089.784
1.110.542

AKUT
PENGOBATAN INDIVIDU
KETERBELAKANGAN MENTAL
PROSEDUR KRANIOTOMI

MATA
PROSEDUR SEDANG PADA SEGMEN
ANTERIOR MATA
MATA
MATA
MATA
56
H-2-31-0
57
H-2-32-0
58
H-2-33-0
59
H-2-34-0
60
H-2-35-0
61
H-2-36-0
62
H-2-37-0

63
H-3-10-0
361.110
371.943
379.165
386.387
64
H-3-11-0
189.904
195.601
199.399
203.197
- 550 No
Kode
INA-CBG
65
H-3-12-0
66
H-3-13-0
67
I-2-11-0
68
I-2-12-0
69
I-2-13-0
70
I-2-14-0
71
I-2-15-0
Deskripsi (INA-CBG)
MATA
TORASIK
ABDOMEN
PROSEDUR PEMASANGAN/PENYISIPAN
ALAT PACU PERMANEN PADA JANTUNG
PENGGANTIAN ALAT
PEMBULUH DARAH VENA
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
198.269
204.217
208.183
212.148
192.507
198.283
202.133
205.983
2.150.214
2.214.720
2.257.725
2.300.729
1.511.835
1.557.190
1.587.427
1.617.663
1.921.451
1.979.095
2.017.524
2.055.953
3.400.560
3.502.576
3.570.588
3.638.599
204.503
210.638
214.728
218.818
2.147.884
2.212.320
2.255.278
2.298.235
708.096
729.338
743.500
757.662
72
I-2-16-0
73
I-2-17-0
74
I-2-21-0
1.657.861
1.707.597
1.740.754
1.773.911
75
I-2-22-0
PROSEDUR SEDANG PADA PEMBULUH

DARAH
1.561.166
1.608.001
1.639.225
1.670.448
76
I-2-23-0
319.488
329.073
335.462
341.852
2.484.766
2.559.309
2.609.004
2.658.700
3.249.197
3.346.672
3.411.656
3.476.640

PACU JANTUNG
77
I-2-31-0
78
I-2-32-0
79
I-2-41-0
2.178.626
2.243.985
2.287.558
2.331.130
80
I-2-42-0

KORONER DAN KARDIOVASKULAR
PERKUTAN LAIN
2.533.013
2.609.004
2.659.664
2.710.324
81
I-3-10-0
PROSEDUR RESUSITASI
321.544
331.190
337.621
344.052
82
I-3-11-0
169.710
174.801
178.195
181.590
83
I-3-12-0
986.290
1.015.879
1.035.605
1.055.331
84
I-3-13-0
323.936
333.654
340.133
346.611
85
I-3-14-0
207.632
213.861
218.013
222.166
86
I-3-15-0
183.932
189.450
193.129
196.808
87
J-2-10-0
1.138.791
1.172.955
1.195.730
1.218.506
88
J-2-21-0
183.573
189.080
192.752
196.423
89
J-2-22-0
925.093
952.845
971.347
989.849
90
J-2-31-0
PROSEDUR
1.199.928
1.235.926
1.259.924
1.283.923
91
J-2-32-0
892.945
919.734
937.593
955.452
92
J-3-10-0
185.730
191.302
195.017
198.731
93
J-3-11-0

PADA DADA
524.840
540.586
551.082
561.579
94
J-3-12-0
202.771
208.854
212.909
216.965
95
J-3-13-0
298.428
307.381
313.350
319.318
96
J-3-14-0
316.814
326.318
332.655
338.991

KARDIOVASKULAR
PERNAFASAN
PENDEK
No
Kode
INA-CBG
97
J-3-15-0
277.821
98
J-3-16-0
99
J-3-17-0
100
K-2-10-0
101
K-2-11-0
102
K-2-12-0
103
K-2-13-0
104
K-2-14-0
105
K-2-21-0
106
K-2-22-0
107
K-2-31-0
108
K-2-32-0
109
K-2-41-0
110
Deskripsi (INA-CBG)
Regional 3
Regional 4
286.155
291.712
297.268
316.814
326.318
332.655
338.991
185.730
191.302
195.017
198.731
534.595
550.633
561.325
572.017
1.141.578
1.175.826
1.198.657
1.221.489
876.309
902.598
920.124
937.650
1.426.240
1.469.027
1.497.552
1.526.077
185.730
191.302
195.017
198.731
185.730
191.302
195.017
198.731
2.387.075
2.458.687
2.506.429
2.554.170
802.652
826.732
842.785
858.838
185.730
191.302
195.017
198.731
884.138
910.662
928.345
946.027
K-2-42-0

252.609
260.187
265.240
270.292
111
K-2-51-0
585.883
603.460
615.177
626.895
112
K-2-52-0
319.488
329.073
335.462
341.852
113
K-2-53-0
185.730
191.302
195.017
198.731
114
K-3-10-0

GASTROINTESTINAL
353.432
364.035
371.104
378.172
115
K-3-11-0
212.482
218.856
223.106
227.355
116
K-3-12-0
215.483
221.948
226.257
230.567
117
K-3-13-0
185.730
191.302
195.017
198.731
118
K-3-14-0
497.761
512.694
522.649
532.604
119
K-3-15-0
240.376
247.587
252.394
257.202
120
K-3-16-0
318.513
328.068
334.439
340.809
121
L-2-21-0
1.095.060
1.127.911
1.149.813
1.171.714
122
L-2-22-0
701.925
722.983
737.022
751.060
123
L-2-31-0
316.814
326.318
332.655
338.991
124
L-2-32-0
319.488
329.073
335.462
341.852
125
L-2-41-0
956.669
985.369
1.004.502
1.023.636
126
L-2-42-0

214.565
221.002
225.294
229.585
127
L-2-51-0
1.432.283
1.475.252
1.503.897
1.532.543
128
L-2-52-0

1.095.744
1.128.616
1.150.531
1.172.446

SALURAN PERNAFASAN
KECIL
PROSEDUR ADHESIOLYSIS PADA
PERITONEUM
FEMORALIS
USUS BESAR
ATAS

GASTROINTESTINAL
PADA LUKA BAKAR
PADA LUKA BAKAR
TANPA LUKA BAKAR
TANPA LUKA BAKAR
Regional 1
Regional 2
- 552 No
Kode
INA-CBG
129
L-2-53-0
130
L-3-10-0
131
L-3-11-0
132
L-3-12-0
133
M-2-10-0
134
M-2-21-0
135
M-2-22-0
136
M-2-31-0
137
Deskripsi (INA-CBG)
PAYUDARA
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
185.730
191.302
195.017
198.731
252.609
260.187
265.240
270.292
245.301
252.660
257.566
262.472
186.820
192.425
196.161
199.897
1.465.330
1.509.290
1.538.597
1.567.903
1.312.305
1.351.674
1.377.920
1.404.166
319.488
329.073
335.462
341.852
PROSEDUR BUNION
797.093
821.006
836.948
852.890
M-2-32-0
252.609
260.187
265.240
270.292
138
M-2-41-0

TULANG
252.609
260.187
265.240
270.292
139
M-2-42-0
87.056
89.668
91.409
93.150
140
M-2-51-0
185.730
191.302
195.017
198.731
141
M-2-52-0
185.730
191.302
195.017
198.731
142
M-2-61-0
PROSEDUR ARTROSKOPI
910.361
937.672
955.879
974.086
185.730
191.302
195.017
198.731
915.285
942.744
961.050
979.355
1.248.260
1.285.708
1.310.673
1.335.639
185.730
191.302
195.017
198.731
921.544
949.191
967.621
986.052
889.329
916.009
933.796
951.583
1.326.180
1.365.965
1.392.489
1.419.012
963.384
992.286
1.011.554
1.030.821
185.730
191.302
195.017
198.731
185.730
191.302
195.017
198.731
530.110
546.013
556.615
567.217
293.914
302.731
308.609
314.487
664.663
684.603
697.896
711.189

DAN WAJAH
PROSEDUR BESAR PADA SENDI PANGGUL
DAN PAHA
PROSEDUR KECIL PADA SENDI PANGGUL
DAN PAHA
PROSEDUR LAIN-LAIN PADA SENDI &

TULANG
TULANG
WAJAH
WAJAH
BAWAH
BAWAH
BAHU
BAHU
PERGELANGAN TANGAN
PERGELANGAN TANGAN
143
M-2-62-0
144
M-2-63-0
145
M-2-64-0
146
M-2-65-0
147
M-2-71-0
148
M-2-72-0
149
M-2-81-0
150
M-2-82-0
151
M-2-83-0
152
M-2-84-0
153
M-3-10-0
154
M-3-11-0
155
M-3-12-0
156
M-3-13-0
216.698
223.199
227.533
231.867
157
M-3-14-0

TERTUTUP
370.374
381.485
388.892
396.300
158
M-3-15-0
163.172
168.067
171.331
174.594
159
M-3-16-0

185.730
191.302
195.017
198.731
160
M-3-17-0
202.771
208.854
212.909
216.965

MUSKULOSKELETAL
SKELETAL
- 553 No
Kode
INA-CBG
161
N-2-11-0
Deskripsi (INA-CBG)
LITHOTRIPSY (ESWL) PADA SALURAN KEMIH
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.453.678
2.527.288
2.576.362
2.625.435
1.419.428
1.462.011
1.490.400
1.518.788
1.411.946
1.454.305
1.482.544
1.510.783
162
N-2-12-0
163
N-2-21-0
164
N-2-22-0
319.488
329.073
335.462
341.852
165
N-2-23-0

URETER
319.488
329.073
335.462
341.852
166
N-2-24-0
1.032.478
1.063.452
1.084.102
1.104.751
167
N-2-31-0
869.179
895.254
912.638
930.022
168
N-2-32-0
319.488
329.073
335.462
341.852
169
N-2-41-0
319.488
329.073
335.462
341.852
170
N-2-42-0
540.315
556.525
567.331
578.138
171
N-3-10-0
319.488
329.073
335.462
341.852
172
N-3-11-0
370.172
381.278
388.681
396.085
173
N-3-12-0
286.049
294.630
300.351
306.072
174
N-3-13-0
319.488
329.073
335.462
341.852
175
N-3-14-0
274.902
283.149
288.647
294.145
176
N-3-15-0
704.918
726.066
740.164
754.262
177
O-7-10-0
117.691
121.222
123.575
125.929
178
O-7-11-0
648.155
667.600
680.563
693.526
179
O-7-12-0
236.015
243.096
247.816
252.536
180
O-7-13-0
131.167
135.102
137.725
140.348
181
P-9-10-0
174.944
180.192
183.691
187.190
182
P-9-11-0
174.944
180.192
183.691
187.190
183
P-9-12-0
174.944
180.192
183.691
187.190
184
P-9-13-0
174.944
180.192
183.691
187.190
174.944
180.192
183.691
187.190
111.513
114.858
117.088
119.319
174.944
180.192
183.691
187.190
174.191
179.417
182.901
186.385

DAN URETHRA
DAN URETHRA
TRANSURETHRA
TRANSURETHRA
SALURAN KEMIH
SALURAN KEMIH
PROSEDUR KECIL ENDOSKOPI PADA
SALURAN KEMIH
PROSEDUR DIALISIS
CAESAR
VAGINAL/JALAN LAHIR
LAIN

HEREDITER
ASPIRASI
185
P-9-14-0
186
P-9-15-0
187
P-9-16-0
188
P-9-17-0
189
Q-5-10-0
228.007
234.848
239.408
243.968
190
Q-5-11-0
PENYALAHGUNAAN ZAT KIMIA BUKAN

AKUT
170.885
176.012
179.430
182.847
191
Q-5-12-0
GIGI
150.614
155.132
158.144
161.157
No
Kode
INA-CBG
192
Q-5-13-0
MEDICAL CHECK-UP
114.460
193
Q-5-14-0
194
Q-5-15-0
195
Deskripsi (INA-CBG)
Regional 3
Regional 4
117.894
120.183
122.472
125.943
129.722
132.240
134.759
86.611
89.209
90.942
92.674
Q-5-16-0
VAKSINASI
97.891
100.827
102.785
104.743
196
Q-5-17-0
PASANG INFUS
84.673
87.213
88.906
90.600
197
Q-5-18-0
159.381
164.162
167.350
170.537
198
Q-5-19-0
178.178
183.523
187.087
190.651
199
Q-5-20-0
ABORSI MENGANCAM
119.427
123.010
125.398
127.787
200
Q-5-21-0
ABORSI
117.800
121.334
123.690
126.046
201
Q-5-22-0
125.943
129.722
132.240
134.759
202
Q-5-23-0
154.188
158.813
161.897
164.981
203
Q-5-24-0
105.308
108.467
110.573
112.680
204
Q-5-25-0
164.226
169.153
172.437
175.722
205
Q-5-26-0
BRONKIAL AKUT
232.450
239.424
244.073
248.722
206
Q-5-27-0
165.423
170.386
173.694
177.003
207
Q-5-28-0
134.236
138.264
140.948
143.633
208
Q-5-29-0

JANTUNG LAIN-LAIN
380.046
391.447
399.048
406.649
209
Q-5-30-0
440.432
453.645
462.453
471.262
210
Q-5-31-0
FRAKTUR
157.128
161.842
164.985
168.127
211
Q-5-32-0
SALURAN KEMIH AKUT
181.990
187.450
191.090
194.729
212
Q-5-33-0
HEMATOLOGI AKUT
190.543
196.259
200.070
203.881
213
Q-5-34-0
INFEKSI VIRUS HIV
270.680
278.800
284.214
289.627
214
Q-5-35-0
INFEKSI AKUT
306.943
316.152
322.291
328.430
215
Q-5-36-0
357.456
368.179
375.328
382.477
216
Q-5-37-0

SHOCK
182.321
187.790
191.437
195.083
217
Q-5-38-0
PARU AKUT
243.130
250.424
255.287
260.150
218
Q-5-39-0
KECEDERAAN BESAR PADA JARINGAN

LUNAK
155.586
160.253
163.365
166.477
219
Q-5-40-0
152.654
157.234
160.287
163.340
220
Q-5-41-0
211.328
217.668
221.895
226.121
221
Q-5-42-0
165.690
170.660
173.974
177.288
222
Q-5-43-0
238.603
245.761
250.533
255.305
223
Q-5-44-0
194.733
200.575
204.470
208.364
224
T-2-10-0

TERAPI DETOKSIKASI
101.005
104.035
106.055
108.075
225
U-2-10-0
1.348.022
1.388.463
1.415.423
1.442.384
KONSULTASI ATAU PEMERIKSAAN LAINLAIN

Regional 1
Regional 2
- 555 No
Kode
INA-CBG
226
U-2-11-0
PROSEDUR BESAR LAIN-LAIN PADA KEPALA

& LEHER
227
U-2-12-0
228
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.602.274
1.650.343
1.682.388
1.714.434
176.292
181.581
185.107
188.632
U-2-13-0
231.123
238.057
242.679
247.302
229
U-2-14-0

LANGIT-LANGIT MULUT
429.322
442.202
450.788
459.375
230
U-2-15-0
243.931
251.249
256.128
261.007
231
U-2-21-0
284.142
292.666
298.349
304.032
232
U-2-22-0
548.985
565.455
576.434
587.414
233
U-2-23-0
719.348
740.928
755.315
769.702
234
U-2-24-0
606.254
624.442
636.567
648.692
235
U-2-25-0
231.123
238.057
242.679
247.302
236
U-2-31-0
185.730
191.302
195.017
198.731
237
U-2-32-0
231.123
238.057
242.679
247.302
220.966
227.595
232.014
236.434
234.597
241.635
246.327
251.019
103.738
106.851
108.925
111.000
228.025
234.866
239.427
243.987
209.508
215.793
219.984
224.174
182.710
188.191
191.845
195.499
206.063
212.245
216.367
220.488
2.010.387
2.070.699
2.110.907
2.151.114
226.721
233.522
238.057
242.591
723.497
745.202
759.672
774.142
319.488
329.073
335.462
341.852
319.488
329.073
335.462
341.852

PROSEDUR SEDANG PADA TELINGA,
(RHINOPLASTY)

TENGGOROKAN
RONGGA HIDUNG
TENGGOROKAN
238
U-3-10-0
239
U-3-11-0
240
U-3-12-0
241
U-3-13-0
242
U-3-14-0
243
U-3-15-0
244
U-3-16-0
PROSEDUR PADA GIGI
245
V-2-10-0

PROSTAT
246
V-2-11-0
PROSEDUR PADA PENIS

SKROTUM
SKROTUM
TRANSURETHRAL
247
V-2-12-0
248
V-2-13-0
249
V-2-14-0
250
V-2-15-0
SIRKUMSISI/SUNAT
174.944
180.192
183.691
187.190
251
V-3-10-0
364.857
375.802
383.100
390.397
252
V-3-11-0
771.861
795.017
810.454
825.891
253
V-3-12-0
445.616
458.984
467.897
476.809
254
W-2-10-0
163.172
168.067
171.331
174.594
255
W-2-11-0
417.007
429.518
437.858
446.198
256
W-2-12-0
771.861
795.017
810.454
825.891

PROSEDUR ABORSI
RAHIM & LEHER RAHIM
TERHALANG/TERGANGGU
- 556 No
Kode
INA-CBG
257
W-2-13-0
258
W-2-21-0
259
W-2-22-0
260
W-2-23-0
261
W-2-31-0
262
W-2-32-0
263
W-2-33-0
264
Deskripsi (INA-CBG)
TERHALANG/TERGANGGU
PANGGUL TERBUKA
PANGGUL TERBUKA
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
123.793
127.507
129.982
132.458
1.551.647
1.598.196
1.629.229
1.660.262
163.172
168.067
171.331
174.594
544.514
560.849
571.739
582.630
1.787.473
1.841.097
1.876.846
1.912.596
1.253.636
1.291.245
1.316.317
1.341.390
532.812
548.796
559.452
570.109
W-2-34-0
181.219
186.655
190.280
193.904
265
W-3-10-0
440.431
453.644
462.453
471.262
266
W-3-11-0
352.068
362.630
369.672
376.713
267
W-3-12-0
163.172
168.067
171.331
174.594
268
Z-3-10-0
1.847.327
1.902.747
1.939.693
1.976.640
269
Z-3-11-0
LITHOTRIPSY (ESWL) SELAIN URINARI DAN
SALURAN EMPEDU
1.411.946
1.454.305
1.482.544
1.510.783
270
Z-3-12-0
235.761
242.834
247.549
252.264
271
Z-3-13-0

LAIN-LAIN
1.438.678
1.481.838
1.510.611
1.539.385
272
Z-3-14-0
DIAGNOSTIK TIDUR
284.471
293.005
298.695
304.384
273
Z-3-15-0
185.730
191.302
195.017
198.731
274
Z-3-16-0
PROSEDUR MAGNETIC RESONANCE

IMAGING (MRI)
596.137
614.022
625.944
637.867
275
Z-3-17-0
PENGOBATAN NUKLIR
250.271
257.780
262.785
267.790
276
Z-3-18-0
CT-SCAN KEPALA
241.132
248.366
253.188
258.011
277
Z-3-19-0
CT SCAN LAIN-LAIN
250.971
258.500
263.520
268.539
278
Z-3-20-0
170.692
175.812
179.226
182.640
279
Z-3-21-0
163.172
168.067
171.331
174.594
280
Z-3-22-0
183.962
189.481
193.160
196.839
281
Z-3-23-0
191.612
197.361
201.193
205.025
282
Z-3-24-0
PROSEDUR ULTRASOUND PEMBULUH

DARAH
376.480
387.775
395.304
402.834
283
Z-3-25-0
167.684
172.714
176.068
179.422
284
Z-3-26-0
189.516
195.201
198.992
202.782
285
Z-3-27-0
PERAWATAN LUKA
180.936
186.364
189.983
193.602
286
Z-3-28-0
IMAGING PAYUDARA
185.730
191.302
195.017
198.731
287
Z-3-29-0
IMAGING LAIN-LAIN
535.308
551.367
562.073
572.779
288
Z-3-30-0
FOTOTERAPI
90.340
93.050
94.857
96.664

JALAN LAHIR
- 557 4. RUMAH SAKIT ORTOPEDI KELAS B NON PENDIDIKAN

a. RawatInap
No
Kode
INA-CBG
A-4-10-i
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
SEPTIKEMIA RINGAN
1.594.924
1.642.772
1.674.670
1.706.569
A-4-10-ii
SEPTIKEMIA SEDANG
2.725.868
2.807.644
2.862.162
2.916.679
A-4-10-iii
SEPTIKEMIA BERAT
3.902.402
4.019.474
4.097.522
4.175.570
A-4-11-i
4.279.626
4.408.015
4.493.607
4.579.200
A-4-11-ii
6.611.528
6.809.873
6.942.104
7.074.335
A-4-11-iii
7.410.972
7.633.301
7.781.521
7.929.740
A-4-12-i
DEMAM RINGAN
1.532.986
1.578.975
1.609.635
1.640.295
A-4-12-ii
DEMAM SEDANG
2.407.908
2.480.145
2.528.303
2.576.461
A-4-12-iii
DEMAM BERAT
2.755.674
2.838.344
2.893.457
2.948.571
10
A-4-13-i
1.916.232
1.973.719
2.012.044
2.050.369
11
A-4-13-ii
2.299.479
2.368.463
2.414.453
2.460.442
12
A-4-13-iii
2.794.745
2.878.587
2.934.482
2.990.377
1.532.986
1.578.975
1.609.635
1.640.295
2.394.989
2.466.839
2.514.739
2.562.639
2.672.738
2.752.920
2.806.375
2.859.830

LAIN-LAIN RINGAN
LAIN-LAIN SEDANG
LAIN-LAIN BERAT
13
A-4-14-i
14
A-4-14-ii
15
A-4-14-iii
16
A-4-15-i
INFEKSI HIV RINGAN
2.299.479
2.368.463
2.414.453
2.460.442
17
A-4-15-ii
INFEKSI HIV SEDANG
3.449.218
3.552.695
3.621.679
3.690.664
18
A-4-15-iii
INFEKSI HIV BERAT
5.253.405
5.411.007
5.516.076
5.621.144
19
B-1-01-i
25.493.308
26.258.107
26.767.974
27.277.840
20
B-1-01-ii
28.125.935
28.969.713
29.532.231
30.094.750
21
B-1-01-iii
49.338.677
50.818.837
51.805.611
52.792.384
22
B-1-10-i
3.305.121
3.404.275
3.470.377
3.536.479
23
B-1-10-ii
8.423.040
8.675.731
8.844.192
9.012.653
24
B-1-10-iii
16.055.934
16.537.612
16.858.731
17.179.850
2.474.432
2.548.665
2.598.154
2.647.642
6.211.058
6.397.390
6.521.611
6.645.832
7.787.125
8.020.739
8.176.482
8.332.224
5.278.053
5.436.394
5.541.955
5.647.516
11.312.158
11.651.523
11.877.766
12.104.009
13.767.323
14.180.343
14.455.689
14.731.036
25
B-1-11-i
26
B-1-11-ii
27
B-1-11-iii
28
B-1-12-i
29
B-1-12-ii
30
B-1-12-iii

(RINGAN)
(SEDANG)
(BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT
- 558 No
Kode
INA-CBG
31
B-1-13-i
32
B-1-13-ii
33
B-1-13-iii
34
B-1-14-i
35
B-1-14-ii
36
B-1-14-iii
37
B-4-10-i
38
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.458.591
3.562.348
3.631.520
3.700.692
5.633.542
5.802.548
5.915.219
6.027.890
8.305.422
8.554.584
8.720.693
8.886.801
4.696.523
4.837.418
4.931.349
5.025.279
5.223.481
5.380.185
5.484.655
5.589.125
8.171.515
8.416.660
8.580.091
8.743.521
1.314.016
1.353.436
1.379.716
1.405.997
B-4-10-ii
1.916.232
1.973.719
2.012.044
2.050.369
39
B-4-10-iii
3.208.401
3.304.653
3.368.821
3.432.989
40
B-4-11-i
3.172.526
3.267.702
3.331.152
3.394.603
41
B-4-11-ii
4.823.032
4.967.723
5.064.183
5.160.644
42
B-4-11-iii
5.194.573
5.350.410
5.454.301
5.558.193
43
B-4-12-i
2.783.674
2.867.184
2.922.858
2.978.531
44
B-4-12-ii
3.946.565
4.064.962
4.143.893
4.222.825
45
B-4-12-iii
7.500.355
7.725.366
7.875.373
8.025.380
46
B-4-13-i
2.299.479
2.368.463
2.414.453
2.460.442
47
B-4-13-ii
2.725.522
2.807.288
2.861.798
2.916.309
48
B-4-13-iii
4.845.307
4.990.666
5.087.573
5.184.479
49
B-4-14-i
2.410.653
2.482.972
2.531.185
2.579.398
50
B-4-14-ii
2.708.909
2.790.176
2.844.354
2.898.533
51
B-4-14-iii
3.579.026
3.686.396
3.757.977
3.829.557
52
C-4-10-i
2.452.252
2.525.819
2.574.864
2.623.909
53
C-4-10-ii
4.764.468
4.907.402
5.002.691
5.097.980
54
C-4-10-iii
LEUKEMIA AKUT BERAT
7.281.683
7.500.134
7.645.767
7.791.401
55
C-4-11-i
2.466.957
2.540.966
2.590.305
2.639.644
56
C-4-11-ii
3.065.972
3.157.951
3.219.270
3.280.590
57
C-4-11-iii
5.708.390
5.879.642
5.993.810
6.107.977
58
C-4-12-i
RADIOTERAPI RINGAN
1.532.986
1.578.975
1.609.635
1.640.295
59
C-4-12-ii
RADIOTERAPI SEDANG
4.622.306
4.760.975
4.853.421
4.945.867
60
C-4-12-iii
RADIOTERAPI BERAT
9.384.207
9.665.733
9.853.417
10.041.101
61
C-4-13-i
KEMOTERAPI RINGAN
1.532.986
1.578.975
1.609.635
1.640.295
62
C-4-13-ii
KEMOTERAPI SEDANG
3.065.972
3.157.951
3.219.270
3.280.590
63
C-4-13-iii
KEMOTERAPI BERAT
4.011.597
4.131.945
4.212.177
4.292.409

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT

PANCREAS RINGAN
PANCREAS SEDANG
PANCREAS BERAT
(RINGAN)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT
- 559 No
Kode
INA-CBG
64
C-4-14-i
65
C-4-14-ii
66
C-4-14-iii
67
D-1-10-i
68
D-1-10-ii
69
D-1-10-iii
70
D-1-11-i
71
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.176.984
2.242.293
2.285.833
2.329.373
3.181.148
3.276.582
3.340.205
3.403.828
4.849.568
4.995.055
5.092.046
5.189.038
16.312.788
16.802.172
17.128.428
17.454.683
24.845.628
25.590.997
26.087.909
26.584.822
33.672.615
34.682.793
35.356.245
36.029.698
3.671.928
3.782.086
3.855.525
3.928.963
D-1-11-ii
9.577.063
9.864.374
10.055.916
10.247.457
72
D-1-11-iii
13.176.554
13.571.851
13.835.382
14.098.913
73
D-1-20-i
4.130.132
4.254.036
4.336.638
4.419.241
74
D-1-20-ii
9.292.796
9.571.580
9.757.436
9.943.292
75
D-1-20-iii
18.069.326
18.611.405
18.972.792
19.334.178
76
D-4-10-i
1.472.527
1.516.703
1.546.153
1.575.604
77
D-4-10-ii
2.973.309
3.062.509
3.121.975
3.181.441
78
D-4-10-iii
3.832.465
3.947.439
4.024.088
4.100.737
79
D-4-11-i
1.916.232
1.973.719
2.012.044
2.050.369
80
D-4-11-ii
3.533.012
3.639.002
3.709.663
3.780.323
81
D-4-11-iii
5.352.021
5.512.582
5.619.622
5.726.663
82
D-4-12-i
1.965.689
2.024.660
2.063.973
2.103.287
83
D-4-12-ii
2.726.604
2.808.402
2.862.934
2.917.466
84
D-4-12-iii
4.186.701
4.312.302
4.396.036
4.479.770
85
D-4-13-i
1.532.986
1.578.975
1.609.635
1.640.295
86
D-4-13-ii
2.299.479
2.368.463
2.414.453
2.460.442
87
D-4-13-iii
2.682.725
2.763.207
2.816.862
2.870.516
88
D-4-14-i
1.916.232
1.973.719
2.012.044
2.050.369
89
D-4-14-ii
4.312.436
4.441.809
4.528.058
4.614.306
90
D-4-14-iii
5.144.139
5.298.463
5.401.346
5.504.229
91
E-1-01-i
4.024.315
4.145.045
4.225.531
4.306.018
92
E-1-01-ii
5.271.470
5.429.614
5.535.044
5.640.473
93
E-1-01-iii
10.910.013
11.237.313
11.455.514
11.673.714
94
E-1-10-i
3.744.352
3.856.683
3.931.570
4.006.457
95
E-1-10-ii
4.544.765
4.681.108
4.772.003
4.862.898
96
E-1-10-iii
9.579.026
9.866.397
10.057.978
10.249.558

RINGAN
SEDANG
BERAT
TULANG RINGAN
TULANG SEDANG
TULANG BERAT


RINGAN
SEDANG
BERAT
- 560 No
Kode
INA-CBG
97
E-1-20-i
98
E-1-20-ii
99
E-1-20-iii
100
E-4-10-i
101
E-4-10-ii
102
E-4-10-iii
103
E-4-11-i
104
E-4-11-ii
105
E-4-11-iii
106
E-4-12-i
107
E-4-12-ii
108
E-4-12-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.748.536
4.890.992
4.985.962
5.080.933
6.359.896
6.550.693
6.677.891
6.805.089
14.091.733
14.514.485
14.796.320
15.078.154
1.948.457
2.006.911
2.045.880
2.084.849
2.984.549
3.074.086
3.133.777
3.193.467
5.209.330
5.365.610
5.469.797
5.573.983
1.790.484
1.844.198
1.880.008
1.915.817
3.387.287
3.488.906
3.556.652
3.624.398
5.585.793
5.753.367
5.865.083
5.976.799
2.107.856
2.171.091
2.213.248
2.255.406
3.449.218
3.552.695
3.621.679
3.690.664
5.541.579
5.707.827
5.818.658
5.929.490
2.256.625
2.324.323
2.369.456
2.414.588
3.874.640
3.990.880
4.068.372
4.145.865
6.704.106
6.905.230
7.039.312
7.173.394

RINGAN
SEDANG
BERAT

RINGAN
SEDANG
BERAT
109
E-4-13-i
110
E-4-13-ii
111
E-4-13-iii
112
F-4-10-i
SCHIZOFRENIA RINGAN
2.759.151
2.841.925
2.897.108
2.952.291
113
F-4-10-ii
SCHIZOFRENIA SEDANG
3.064.125
3.156.049
3.217.332
3.278.614
114
F-4-10-iii
SCHIZOFRENIA BERAT
4.536.505
4.672.600
4.763.331
4.854.061
115
F-4-11-i
2.543.268
2.619.567
2.670.432
2.721.297
116
F-4-11-ii
2.963.149
3.052.044
3.111.307
3.170.570
117
F-4-11-iii
DEPRESI MAYOR BERAT
3.799.840
3.913.835
3.989.832
4.065.829
1.241.967
1.279.226
1.304.065
1.328.904
1.641.665
1.690.915
1.723.748
1.756.581
3.561.316
3.668.156
3.739.382
3.810.609

IMPULSE RINGAN
IMPULSE SEDANG
IMPULSE BERAT
118
F-4-12-i
119
F-4-12-ii
120
F-4-12-iii
121
F-4-13-i
2.055.347
2.117.008
2.158.115
2.199.222
122
F-4-13-ii
2.721.808
2.803.462
2.857.899
2.912.335
123
F-4-13-iii
3.509.424
3.614.707
3.684.895
3.755.084
124
F-4-14-i
DEPRESI RINGAN
1.438.743
1.481.906
1.510.680
1.539.455
125
F-4-14-ii
DEPRESI SEDANG
1.845.480
1.900.844
1.937.754
1.974.663
126
F-4-14-iii
DEPRESI BERAT
2.483.176
2.557.671
2.607.334
2.656.998
127
F-4-15-i
1.710.584
1.761.901
1.796.113
1.830.325
128
F-4-15-ii
2.408.148
2.480.392
2.528.555
2.576.718
129
F-4-15-iii
3.028.555
3.119.411
3.179.982
3.240.554
- 561 No
Kode
INA-CBG
130
F-4-16-i
131
F-4-16-ii
132
F-4-16-iii
133
F-4-17-i
134
F-4-17-ii
135
F-4-17-iii
136
F-4-18-i
137
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.684.263
3.794.791
3.868.476
3.942.161
4.282.863
4.411.349
4.497.006
4.582.663
5.716.907
5.888.415
6.002.753
6.117.091
776.758
800.060
815.596
831.131
2.276.603
2.344.901
2.390.433
2.435.965
2.428.968
2.501.837
2.550.416
2.598.996
3.193.395
3.289.197
3.353.064
3.416.932
F-4-18-ii
3.513.636
3.619.045
3.689.318
3.759.591
138
F-4-18-iii
5.416.576
5.579.074
5.687.405
5.795.737
139
F-4-19-i
2.449.032
2.522.503
2.571.484
2.620.465
140
F-4-19-ii
3.136.049
3.230.131
3.292.852
3.355.572
141
F-4-19-iii
3.904.423
4.021.556
4.099.644
4.177.733
142
G-1-01-i
7.109.639
7.322.928
7.465.121
7.607.314
143
G-1-01-ii
12.033.921
12.394.938
12.635.617
12.876.295
144
G-1-01-iii
23.296.327
23.995.216
24.461.143
24.927.069
145
G-1-10-i
3.885.605
4.002.173
4.079.885
4.157.597
146
G-1-10-ii
5.485.508
5.650.074
5.759.784
5.869.494
147
G-1-10-iii
6.501.499
6.696.544
6.826.574
6.956.604
148
G-1-11-i
4.482.161
4.616.626
4.706.270
4.795.913
149
G-1-11-ii
9.204.456
9.480.590
9.664.679
9.848.768
150
G-1-11-iii
19.273.294
19.851.493
20.236.959
20.622.425
151
G-1-12-i
3.485.801
3.590.375
3.660.091
3.729.807
152
G-1-12-ii
7.980.394
8.219.806
8.379.414
8.539.022
153
G-1-12-iii
13.739.952
14.152.151
14.426.950
14.701.749
154
G-1-13-i
1.056.601
1.088.299
1.109.431
1.130.563
155
G-1-13-ii
2.837.914
2.923.052
2.979.810
3.036.568
156
G-1-13-iii
6.403.530
6.595.636
6.723.706
6.851.777
4.392.406
4.524.178
4.612.026
4.699.874
5.934.284
6.112.313
6.230.998
6.349.684
14.529.397
14.965.279
15.255.867
15.546.455

RINGAN
SEDANG
BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

RINGAN
SEDANG
BERAT
157
G-1-20-i
158
G-1-20-ii
159
G-1-20-iii
160
G-1-30-i
7.051.246
7.262.784
7.403.809
7.544.834
161
G-1-30-ii
18.404.429
18.956.562
19.324.651
19.692.739
162
G-1-30-iii
23.692.188
24.402.954
24.876.797
25.350.641
- 562 No
Kode
INA-CBG
163
G-4-10-i
164
G-4-10-ii
165
G-4-10-iii
166
G-4-11-i
167
G-4-11-ii
168
G-4-11-iii
169
G-4-12-i
170
G-4-12-ii
171
G-4-12-iii
172
G-4-13-i
173
G-4-13-ii
174
G-4-13-iii
175
G-4-14-i
176
G-4-14-ii
177
G-4-14-iii
178
G-4-15-i
179
G-4-15-ii
180
G-4-15-iii
181
G-4-16-i
182
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.894.297
2.981.126
3.039.012
3.096.897
3.376.680
3.477.980
3.545.513
3.613.047
5.649.383
5.818.865
5.931.852
6.044.840
4.154.906
4.279.553
4.362.651
4.445.749
4.819.691
4.964.281
5.060.675
5.157.069
7.063.340
7.275.240
7.416.507
7.557.773
3.107.504
3.200.729
3.262.879
3.325.029
3.915.455
4.032.918
4.111.227
4.189.537
5.686.732
5.857.334
5.971.068
6.084.803
1.728.994
1.780.864
1.815.444
1.850.024
2.682.725
2.763.207
2.816.862
2.870.516
3.171.362
3.266.503
3.329.930
3.393.358
3.162.073
3.256.935
3.320.176
3.383.418
5.202.677
5.358.757
5.462.811
5.566.864
6.513.870
6.709.286
6.839.563
6.969.841
2.299.479
2.368.463
2.414.453
2.460.442
2.915.221
3.002.678
3.060.983
3.119.287
4.412.866
4.545.252
4.633.510
4.721.767
1.916.232
1.973.719
2.012.044
2.050.369
G-4-16-ii
2.865.743
2.951.715
3.009.030
3.066.345
183
G-4-16-iii
5.200.811
5.356.836
5.460.852
5.564.868
184
G-4-17-i
2.998.989
3.088.959
3.148.938
3.208.918
185
G-4-17-ii
3.721.877
3.833.534
3.907.971
3.982.409
186
G-4-17-iii
6.237.897
6.425.034
6.549.792
6.674.550
187
G-4-18-i
2.299.479
2.368.463
2.414.453
2.460.442
188
G-4-18-ii
3.610.712
3.719.033
3.791.247
3.863.461
189
G-4-18-iii
3.825.181
3.939.937
4.016.440
4.092.944
190
G-4-19-i
2.097.408
2.160.330
2.202.278
2.244.226
191
G-4-19-ii
3.883.503
4.000.008
4.077.678
4.155.348
192
G-4-19-iii
5.792.953
5.966.742
6.082.601
6.198.460

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
DEGENERATIF RINGAN
DEGENERATIF SEDANG
DEGENERATIF BERAT
RINGAN
SEDANG
BERAT
TRAUMATIK RINGAN
TRAUMATIK SEDANG
TRAUMATIK BERAT
DENGAN INFARK BERAT
TANPA INFARK RINGAN
TANPA INFARK SEDANG
TANPA INFARK BERAT

PERIFER RINGAN
PERIFER SEDANG
PERIFER BERAT
PERSARAFAN RINGAN
PERSARAFAN SEDANG
PERSARAFAN BERAT
SEDANG
- 563 No
Kode
INA-CBG
193
G-4-20-i
194
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.341.363
1.381.604
1.408.431
1.435.258
G-4-20-ii
1.904.736
1.961.879
1.999.973
2.038.068
195
G-4-20-iii
3.248.022
3.345.463
3.410.423
3.475.383
196
G-4-21-i
1.702.200
1.753.266
1.787.310
1.821.354
197
G-4-21-ii
3.525.427
3.631.189
3.701.698
3.772.207
198
G-4-21-iii
4.153.368
4.277.969
4.361.037
4.444.104
199
G-4-22-i
1.532.986
1.578.975
1.609.635
1.640.295
200
G-4-22-ii
1.916.232
1.973.719
2.012.044
2.050.369
201
G-4-22-iii
2.198.419
2.264.372
2.308.340
2.352.309
202
G-4-23-i
1.532.986
1.578.975
1.609.635
1.640.295
203
G-4-23-ii
1.916.232
1.973.719
2.012.044
2.050.369
204
G-4-23-iii
2.739.118
2.821.292
2.876.074
2.930.857
205
G-4-24-i
1.532.986
1.578.975
1.609.635
1.640.295
206
G-4-24-ii
1.916.232
1.973.719
2.012.044
2.050.369
207
G-4-24-iii
TRAUMA KEPALA BERAT
4.026.755
4.147.558
4.228.093
4.308.628
208
G-4-25-i
GEGAR OTAK RINGAN
1.532.986
1.578.975
1.609.635
1.640.295
209
G-4-25-ii
GEGAR OTAK SEDANG
1.916.232
1.973.719
2.012.044
2.050.369
210
G-4-25-iii
GEGAR OTAK BERAT
2.392.780
2.464.564
2.512.419
2.560.275
211
G-4-26-i
2.529.988
2.605.887
2.656.487
2.707.087
212
G-4-26-ii
2.869.090
2.955.163
3.012.545
3.069.927
213
G-4-26-iii
5.120.947
5.274.576
5.376.995
5.479.414
214
H-1-20-i
2.413.126
2.485.519
2.533.782
2.582.045
215
H-1-20-ii
4.400.608
4.532.626
4.620.638
4.708.650
216
H-1-20-iii
5.984.552
6.164.088
6.283.779
6.403.470
217
H-1-30-i
2.362.680
2.433.560
2.480.814
2.528.067
218
H-1-30-ii
2.693.455
2.774.259
2.828.128
2.881.997
219
H-1-30-iii
4.493.932
4.628.750
4.718.629
4.808.508
220
H-4-10-i
2.299.479
2.368.463
2.414.453
2.460.442
221
H-4-10-ii
3.832.465
3.947.439
4.024.088
4.100.737
222
H-4-10-iii
6.248.049
6.435.491
6.560.452
6.685.413
223
H-4-11-i
1.714.641
1.766.080
1.800.373
1.834.666
224
H-4-11-ii
1.892.634
1.949.413
1.987.266
2.025.118
225
H-4-11-iii
2.501.519
2.576.564
2.626.595
2.676.625
226
H-4-12-i
2.378.995
2.450.365
2.497.945
2.545.525

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)

RINGAN
SEDANG
- 564 No
Kode
INA-CBG
227
H-4-12-ii
228
H-4-12-iii
229
I-1-01-i
230
I-1-01-ii
231
I-1-01-iii
232
I-1-02-i
233
I-1-02-ii
234
I-1-02-iii
235
I-1-03-i
236
I-1-03-ii
237
I-1-03-iii
238
I-1-04-i
239
I-1-04-ii
240
I-1-04-iii
241
I-1-05-i
242
I-1-05-ii
243
I-1-05-iii
244
I-1-06-i
245
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.222.505
3.319.180
3.383.630
3.448.080
5.376.530
5.537.826
5.645.356
5.752.887
33.072.334
34.064.505
34.725.951
35.387.398
33.800.098
34.814.101
35.490.103
36.166.105
53.352.807
54.953.391
56.020.447
57.087.503
18.348.341
18.898.791
19.265.758
19.632.725
23.669.359
24.379.440
24.852.827
25.326.215
29.173.862
30.049.078
30.632.555
31.216.032
11.299.561
11.638.548
11.864.539
12.090.530
15.487.993
15.952.633
16.262.393
16.572.153
22.715.724
23.397.195
23.851.510
24.305.824
15.096.547
15.549.444
15.851.375
16.153.306
19.391.783
19.973.536
20.361.372
20.749.208
41.339.255
42.579.433
43.406.218
44.233.003
24.284.569
25.013.106
25.498.797
25.984.488
29.141.482
30.015.727
30.598.556
31.181.386
40.098.496
41.301.451
42.103.420
42.905.390
12.536.208
12.912.294
13.163.019
13.413.743
I-1-06-ii
18.920.114
19.487.717
19.866.120
20.244.522
246
I-1-06-iii
22.241.100
22.908.333
23.353.155
23.797.977
247
I-1-07-i
16.486.063
16.980.645
17.310.366
17.640.087
248
I-1-07-ii
20.338.908
20.949.075
21.355.853
21.762.631
249
I-1-07-iii
22.189.616
22.855.305
23.299.097
23.742.889
250
I-1-11-i
3.136.051
3.230.133
3.292.854
3.355.575
251
I-1-11-ii
3.486.975
3.591.585
3.661.324
3.731.064
252
I-1-11-iii
4.640.101
4.779.304
4.872.106
4.964.908
253
I-1-12-i
8.776.530
9.039.825
9.215.356
9.390.887
254
I-1-12-ii
12.177.845
12.543.180
12.786.737
13.030.294
255
I-1-12-iii
16.985.218
17.494.775
17.834.479
18.174.184

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
KATETERISASI RINGAN
KATETERISASI SEDANG
KATETERISASI BERAT
RINGAN
SEDANG
BERAT

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
- 565 No
Kode
INA-CBG
256
I-1-13-i
257
I-1-13-ii
258
I-1-13-iii
259
I-1-14-i
260
I-1-14-ii
261
I-1-14-iii
262
I-1-15-i
263
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.162.664
5.317.544
5.420.798
5.524.051
6.006.444
6.186.637
6.306.766
6.426.895
11.990.984
12.350.713
12.590.533
12.830.353
18.887.998
19.454.638
19.832.398
20.210.158
23.475.083
24.179.335
24.648.837
25.118.339
30.760.453
31.683.267
32.298.476
32.913.685
4.053.241
4.174.838
4.255.903
4.336.967
I-1-15-ii
10.841.595
11.166.843
11.383.675
11.600.507
264
I-1-15-iii
56.117.717
57.801.248
58.923.602
60.045.957
265
I-1-16-i
8.094.856
8.337.702
8.499.599
8.661.496
266
I-1-16-ii
21.046.626
21.678.025
22.098.957
22.519.890
267
I-1-16-iii
24.276.767
25.005.070
25.490.605
25.976.140
268
I-1-17-i
2.843.058
2.928.349
2.985.210
3.042.072
269
I-1-17-ii
5.889.003
6.065.673
6.183.453
6.301.233
270
I-1-17-iii
34.140.856
35.165.082
35.847.899
36.530.716
271
I-1-20-i
4.594.771
4.732.615
4.824.510
4.916.405
272
I-1-20-ii
7.591.279
7.819.018
7.970.843
8.122.669
273
I-1-20-iii
15.372.064
15.833.225
16.140.667
16.448.108
274
I-1-30-i
9.183.656
9.459.166
9.642.839
9.826.512
275
I-1-30-ii
19.103.861
19.676.976
20.059.054
20.441.131
276
I-1-30-iii
29.604.045
30.492.167
31.084.248
31.676.329
277
I-1-40-i
13.524.829
13.930.574
14.201.070
14.471.567
278
I-1-40-ii
18.326.306
18.876.095
19.242.621
19.609.147
279
I-1-40-iii
22.666.402
23.346.394
23.799.722
24.253.050
280
I-4-10-i
3.933.413
4.051.416
4.130.084
4.208.752
281
I-4-10-ii
6.210.930
6.397.258
6.521.476
6.645.695
282
I-4-10-iii
8.959.808
9.228.603
9.407.799
9.586.995
283
I-4-11-i
4.664.000
4.803.920
4.897.200
4.990.479
284
I-4-11-ii
5.748.697
5.921.158
6.036.132
6.151.106

KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

DARAH VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
- 566 No
Kode
INA-CBG
285
I-4-11-iii
286
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
9.327.246
9.607.063
9.793.608
9.980.153
I-4-12-i
4.085.179
4.207.734
4.289.438
4.371.141
287
I-4-12-ii
5.829.538
6.004.425
6.121.015
6.237.606
288
I-4-12-iii
7.072.050
7.284.212
7.425.653
7.567.094
3.669.613
3.779.702
3.853.094
3.926.486
5.331.200
5.491.135
5.597.759
5.704.383
9.964.408
10.263.341
10.462.629
10.661.917

VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
289
I-4-13-i
290
I-4-13-ii
291
I-4-13-iii
292
I-4-14-i
2.282.161
2.350.625
2.396.269
2.441.912
293
I-4-14-ii
2.670.465
2.750.579
2.803.989
2.857.398
294
I-4-14-iii
4.138.333
4.262.483
4.345.250
4.428.016
3.065.972
3.157.951
3.219.270
3.280.590
4.806.636
4.950.835
5.046.967
5.143.100
5.478.408
5.642.760
5.752.328
5.861.897

295
I-4-15-i
296
I-4-15-ii
297
I-4-15-iii
298
I-4-16-i
2.299.479
2.368.463
2.414.453
2.460.442
299
I-4-16-ii
3.726.663
3.838.463
3.912.996
3.987.530
300
I-4-16-iii
4.694.934
4.835.782
4.929.681
5.023.579
301
I-4-17-i
HIPERTENSI RINGAN
2.253.767
2.321.380
2.366.456
2.411.531
302
I-4-17-ii
HIPERTENSI SEDANG
3.074.549
3.166.785
3.228.276
3.289.767
303
I-4-17-iii
HIPERTENSI BERAT
3.593.530
3.701.336
3.773.207
3.845.077
3.319.152
3.418.726
3.485.109
3.551.492
5.084.718
5.237.260
5.338.954
5.440.649
6.855.015
7.060.666
7.197.766
7.334.866
2.597.671
2.675.601
2.727.555
2.779.508
4.216.943
4.343.451
4.427.790
4.512.129
4.830.374
4.975.285
5.071.893
5.168.500

RINGAN
SEDANG
KONGENITAL BERAT
RINGAN
SEDANG
BERAT
304
I-4-18-i
305
I-4-18-ii
306
I-4-18-iii
307
I-4-19-i
308
I-4-19-ii
309
I-4-19-iii
310
I-4-20-i
3.152.642
3.247.221
3.310.274
3.373.327
311
I-4-20-ii
3.632.079
3.741.042
3.813.683
3.886.325
312
I-4-20-iii
4.820.374
4.964.985
5.061.392
5.157.800
313
I-4-21-i
4.192.504
4.318.279
4.402.129
4.485.979
314
I-4-21-ii
5.229.876
5.386.773
5.491.370
5.595.968
315
I-4-21-iii
7.134.660
7.348.700
7.491.393
7.634.087
316
I-4-22-i
2.491.102
2.565.835
2.615.657
2.665.479
317
I-4-22-ii
2.870.495
2.956.610
3.014.020
3.071.430
- 567 No
Kode
INA-CBG
318
I-4-22-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.187.975
4.313.614
4.397.373
4.481.133
1.887.150
1.943.765
1.981.508
2.019.251
2.316.986
2.386.495
2.432.835
2.479.175
4.527.179
4.662.994
4.753.538
4.844.081
2.464.952
2.538.901
2.588.200
2.637.499
6.154.303
6.338.932
6.462.018
6.585.104
7.781.005
8.014.435
8.170.055
8.325.675
19.859.361
20.455.142
20.852.329
21.249.516
21.215.683
21.852.154
22.276.468
22.700.781
36.247.120
37.334.533
38.059.476
38.784.418
10.151.712
10.456.263
10.659.297
10.862.331
10.875.188
11.201.444
11.418.947
11.636.451
16.070.429
16.552.542
16.873.950
17.195.359
3.961.345
4.080.185
4.159.412
4.238.639
9.568.087
9.855.129
10.046.491
10.237.853
16.941.474
17.449.718
17.788.547
18.127.377
3.423.869
3.526.585
3.595.063
3.663.540
4.979.748
5.129.140
5.228.735
5.328.330
7.488.002
7.712.642
7.862.402
8.012.162
2.308.904
2.378.171
2.424.349
2.470.527
10.325.329
10.635.089
10.841.595
11.048.102
31.140.739
32.074.961
32.697.776
33.320.590
319
I-4-23-i
320
I-4-23-ii
321
I-4-23-iii
322
I-4-24-i
323
I-4-24-ii
324
I-4-24-iii
325
J-1-01-i
326
J-1-01-ii
327
J-1-01-iii
328
J-1-02-i
329
J-1-02-ii
330
J-1-02-iii
331
J-1-10-i
332
J-1-10-ii
333
J-1-10-iii
334
J-1-20-i
335
J-1-20-ii
336
J-1-20-iii
337
J-1-30-i
338
J-1-30-ii
339
J-1-30-iii
340
J-4-10-i
2.433.298
2.506.297
2.554.963
2.603.629
341
J-4-10-ii
3.479.324
3.583.703
3.653.290
3.722.876
342
J-4-10-iii
5.263.697
5.421.608
5.526.882
5.632.156
343
J-4-11-i
1.681.139
1.731.574
1.765.196
1.798.819
344
J-4-11-ii
2.340.108
2.410.311
2.457.113
2.503.915
345
J-4-11-iii
3.353.434
3.454.037
3.521.106
3.588.174
346
J-4-12-i
EMBOLI PARU RINGAN
2.347.569
2.417.996
2.464.947
2.511.899
347
J-4-12-ii
EMBOLI PARU SEDANG
3.040.021
3.131.222
3.192.022
3.252.823
348
J-4-12-iii
EMBOLI PARU BERAT
4.059.641
4.181.430
4.262.623
4.343.816
- 568 No
Kode
INA-CBG
349
J-4-13-i
350
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.960.160
4.078.965
4.158.168
4.237.372
J-4-13-ii
5.821.436
5.996.079
6.112.508
6.228.936
351
J-4-13-iii
9.464.783
9.748.727
9.938.023
10.127.318
352
J-4-14-i
TUMOR PARU RINGAN
2.698.724
2.779.686
2.833.660
2.887.635
353
J-4-14-ii
TUMOR PARU SEDANG
4.520.732
4.656.354
4.746.769
4.837.184
354
J-4-14-iii
TUMOR PARU BERAT
5.374.921
5.536.169
5.643.667
5.751.166
2.362.630
2.433.509
2.480.762
2.528.014
3.326.724
3.426.526
3.493.060
3.559.595
4.180.454
4.305.868
4.389.477
4.473.086
1.916.232
1.973.719
2.012.044
2.050.369
2.777.481
2.860.805
2.916.355
2.971.904
4.839.354
4.984.535
5.081.322
5.178.109

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
355
J-4-15-i
356
J-4-15-ii
357
J-4-15-iii
358
J-4-16-i
359
J-4-16-ii
360
J-4-16-iii
361
J-4-17-i
1.934.271
1.992.299
2.030.984
2.069.670
362
J-4-17-ii
2.625.367
2.704.128
2.756.635
2.809.142
363
J-4-17-iii
4.227.460
4.354.283
4.438.833
4.523.382
364
J-4-18-i
1.532.986
1.578.975
1.609.635
1.640.295
365
J-4-18-ii
2.107.856
2.171.091
2.213.248
2.255.406
366
J-4-18-iii
2.219.443
2.286.026
2.330.415
2.374.804
367
J-4-19-i
2.682.725
2.763.207
2.816.862
2.870.516
368
J-4-19-ii
3.326.699
3.426.500
3.493.034
3.559.568
369
J-4-19-iii
4.803.204
4.947.300
5.043.365
5.139.429
370
J-4-20-i
2.705.818
2.786.993
2.841.109
2.895.225
371
J-4-20-ii
3.583.743
3.691.256
3.762.931
3.834.605
372
J-4-20-iii
7.394.510
7.616.345
7.764.236
7.912.126
1.532.986
1.578.975
1.609.635
1.640.295
3.782.156
3.895.621
3.971.264
4.046.907
5.394.592
5.556.429
5.664.321
5.772.213
4.130.132
4.254.036
4.336.638
4.419.241
6.312.201
6.501.567
6.627.811
6.754.055
7.392.674
7.614.455
7.762.308
7.910.162

USUS BESAR (RINGAN)
USUS BESAR (SEDANG)
USUS BESAR (BERAT)
373
J-4-21-i
374
J-4-21-ii
375
J-4-21-iii
376
K-1-10-i
377
K-1-10-ii
378
K-1-10-iii
379
K-1-11-i
3.889.120
4.005.793
4.083.576
4.161.358
380
K-1-11-ii
5.105.945
5.259.123
5.361.242
5.463.361
381
K-1-11-iii
12.957.883
13.346.620
13.605.778
13.864.935
- 569 No
Kode
INA-CBG
382
K-1-12-i
383
K-1-12-ii
384
K-1-12-iii
385
K-1-13-i
386
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.092.049
2.154.810
2.196.651
2.238.492
2.726.587
2.808.384
2.862.916
2.917.448
5.423.754
5.586.467
5.694.942
5.803.417
2.376.281
2.447.569
2.495.095
2.542.620
K-1-13-ii
4.150.680
4.275.200
4.358.214
4.441.227
387
K-1-13-iii
4.439.002
4.572.172
4.660.952
4.749.732
388
K-1-14-i
3.840.210
3.955.417
4.032.221
4.109.025
389
K-1-14-ii
4.510.762
4.646.085
4.736.300
4.826.515
390
K-1-14-iii
11.106.804
11.440.008
11.662.144
11.884.280
391
K-1-20-i
7.451.134
7.674.668
7.823.691
7.972.714
392
K-1-20-ii
10.399.819
10.711.813
10.919.809
11.127.806
393
K-1-20-iii
22.214.504
22.880.939
23.325.229
23.769.519
394
K-1-30-i
4.904.707
5.051.849
5.149.943
5.248.037
395
K-1-30-ii
8.260.263
8.508.071
8.673.276
8.838.482
396
K-1-30-iii
14.088.113
14.510.756
14.792.519
15.074.281
397
K-1-40-i
4.927.371
5.075.192
5.173.739
5.272.287
398
K-1-40-ii
5.422.082
5.584.745
5.693.186
5.801.628
399
K-1-40-iii
8.992.001
9.261.761
9.441.601
9.621.441
400
K-1-50-i
3.758.395
3.871.147
3.946.315
4.021.483
401
K-1-50-ii
4.867.299
5.013.318
5.110.664
5.208.010
402
K-1-50-iii
PROSEDUR ANAL BERAT
6.910.270
7.117.578
7.255.783
7.393.989
403
K-4-10-i
2.846.714
2.932.115
2.989.050
3.045.984
404
K-4-10-ii
3.406.260
3.508.448
3.576.573
3.644.699
405
K-4-10-iii
12.879.976
13.266.375
13.523.975
13.781.574
406
K-4-11-i
1.532.986
1.578.975
1.609.635
1.640.295
407
K-4-11-ii
2.299.479
2.368.463
2.414.453
2.460.442
408
K-4-11-iii
4.178.982
4.304.351
4.387.931
4.471.510
409
K-4-12-i
1.532.986
1.578.975
1.609.635
1.640.295
410
K-4-12-ii
2.508.135
2.583.379
2.633.542
2.683.704
411
K-4-12-iii
6.019.345
6.199.926
6.320.313
6.440.699
412
K-4-13-i
2.299.479
2.368.463
2.414.453
2.460.442
413
K-4-13-ii
2.978.391
3.067.743
3.127.311
3.186.879


RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)

(RINGAN)
(SEDANG)
- 570 No
Kode
INA-CBG
414
K-4-13-iii
415
K-4-14-i
416
K-4-14-ii
417
K-4-14-iii
418
K-4-15-i
419
K-4-15-ii
420
K-4-15-iii
421
K-4-16-i
422
K-4-16-ii
423
K-4-16-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.871.345
5.017.485
5.114.912
5.212.339
1.916.232
1.973.719
2.012.044
2.050.369
2.593.421
2.671.223
2.723.092
2.774.960
3.922.796
4.040.480
4.118.936
4.197.392
1.916.232
1.973.719
2.012.044
2.050.369
3.603.040
3.711.131
3.783.192
3.855.252
5.126.477
5.280.271
5.382.801
5.485.330
1.916.232
1.973.719
2.012.044
2.050.369
2.299.479
2.368.463
2.414.453
2.460.442
3.073.832
3.166.047
3.227.523
3.289.000
1.532.986
1.578.975
1.609.635
1.640.295
2.449.434
2.522.917
2.571.905
2.620.894
3.259.946
3.357.744
3.422.943
3.488.142
1.673.355
1.723.555
1.757.022
1.790.490
2.606.229
2.684.416
2.736.541
2.788.665
3.030.442
3.121.355
3.181.964
3.242.573
17.179.814
17.695.209
18.038.805
18.382.401
17.811.636
18.345.985
18.702.218
19.058.451
27.381.573
28.203.020
28.750.652
29.298.283
7.227.730
7.444.562
7.589.117
7.733.671
11.287.111
11.625.724
11.851.466
12.077.209
11.904.380
12.261.512
12.499.599
12.737.687
3.146.287
3.240.676
3.303.601
3.366.527
7.081.348
7.293.788
7.435.415
7.577.042
11.849.688
12.205.179
12.442.173
12.679.167

RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
424
K-4-17-i
425
K-4-17-ii
426
K-4-17-iii
427
K-4-18-i
428
K-4-18-ii
429
K-4-18-iii
430
L-1-20-i
431
L-1-20-ii
432
L-1-20-iii
433
L-1-30-i
434
L-1-30-ii
435
L-1-30-iii
436
L-1-40-i
437
L-1-40-ii
438
L-1-40-iii
439
L-1-50-i
5.162.664
5.317.544
5.420.798
5.524.051
440
L-1-50-ii
9.292.796
9.571.580
9.757.436
9.943.292
441
L-1-50-iii
11.236.305
11.573.394
11.798.120
12.022.847
442
L-4-10-i
2.299.479
2.368.463
2.414.453
2.460.442
443
L-4-10-ii
2.887.699
2.974.330
3.032.084
3.089.838
444
L-4-10-iii
5.943.201
6.121.497
6.240.361
6.359.225
445
L-4-11-i
2.381.791
2.453.244
2.500.880
2.548.516
- 571 No
Kode
INA-CBG
446
L-4-11-ii
447
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.263.012
3.360.902
3.426.162
3.491.422
L-4-11-iii
8.848.880
9.114.346
9.291.324
9.468.301
448
L-4-12-i
2.351.247
2.421.784
2.468.809
2.515.834
449
L-4-12-ii
3.694.834
3.805.679
3.879.575
3.953.472
450
L-4-12-iii
5.983.651
6.163.160
6.282.833
6.402.506
451
L-4-13-i
1.580.619
1.628.038
1.659.650
1.691.263
452
L-4-13-ii
1.822.547
1.877.224
1.913.675
1.950.126
453
L-4-13-iii
2.733.963
2.815.982
2.870.662
2.925.341
454
L-4-14-i
1.532.986
1.578.975
1.609.635
1.640.295
455
L-4-14-ii
2.299.479
2.368.463
2.414.453
2.460.442
456
L-4-14-iii
3.937.304
4.055.423
4.134.169
4.212.915
457
M-1-01-i
9.407.216
9.689.433
9.877.577
10.065.721
458
M-1-01-ii
10.499.975
10.814.974
11.024.974
11.234.973
459
M-1-01-iii
14.749.620
15.192.109
15.487.101
15.782.094
460
M-1-02-i
6.009.926
6.190.224
6.310.422
6.430.621
461
M-1-02-ii
9.867.156
10.163.171
10.360.514
10.557.857
462
M-1-02-iii
17.868.967
18.405.036
18.762.415
19.119.795
16.147.831
16.632.266
16.955.222
17.278.179
19.395.850
19.977.726
20.365.643
20.753.560
20.144.163
20.748.488
21.151.371
21.554.254
3.964.568
4.083.505
4.162.796
4.242.088
5.082.535
5.235.011
5.336.662
5.438.313
6.359.835
6.550.630
6.677.826
6.805.023
6.176.036
6.361.317
6.484.838
6.608.358
7.137.842
7.351.978
7.494.734
7.637.491
12.157.690
12.522.420
12.765.574
13.008.728
7.557.975
7.784.715
7.935.874
8.087.034
10.125.325
10.429.085
10.631.592
10.834.098
20.626.248
21.245.035
21.657.560
22.070.085
4.260.793
4.388.617
4.473.833
4.559.049
15.832.999
16.307.989
16.624.649
16.941.309
19.749.100
20.341.573
20.736.555
21.131.537
463
M-1-03-i
464
M-1-03-ii
465
M-1-03-iii
466
M-1-04-i
467
M-1-04-ii
468
M-1-04-iii
469
M-1-05-i
470
M-1-05-ii
471
M-1-05-iii
472
M-1-07-i
473
M-1-07-ii
474
M-1-07-iii
475
M-1-10-i
476
M-1-10-ii
477
M-1-10-iii


TULANG WAJAH RINGAN
TULANG WAJAH SEDANG
TULANG WAJAH BERAT
- 572 No
Kode
INA-CBG
478
M-1-20-i
479
M-1-20-ii
480
M-1-20-iii
481
M-1-30-i
482
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.215.025
4.341.476
4.425.777
4.510.077
6.011.498
6.191.843
6.312.073
6.432.302
11.694.902
12.045.749
12.279.647
12.513.545
2.521.215
2.596.852
2.647.276
2.697.700
M-1-30-ii
5.209.472
5.365.756
5.469.946
5.574.135
483
M-1-30-iii
PROSEDUR KAKI BERAT
7.771.434
8.004.577
8.160.006
8.315.434
484
M-1-40-i
2.824.194
2.908.920
2.965.404
3.021.888
485
M-1-40-ii
5.198.494
5.354.448
5.458.418
5.562.388
486
M-1-40-iii
9.097.364
9.370.285
9.552.232
9.734.179
487
M-1-50-i
3.373.832
3.475.047
3.542.524
3.610.001
488
M-1-50-ii
6.791.604
6.995.352
7.131.184
7.267.016
489
M-1-50-iii
10.396.987
10.708.897
10.916.837
11.124.776
2.546.179
2.622.564
2.673.488
2.724.411
5.097.467
5.250.391
5.352.340
5.454.289
8.871.395
9.137.537
9.314.965
9.492.393
3.410.856
3.513.182
3.581.399
3.649.616
6.959.835
7.168.630
7.307.827
7.447.024
11.220.095
11.556.698
11.781.100
12.005.502

SENDI MAYOR RINGAN
SENDI MAYOR SEDANG
SENDI MAYOR BERAT

RINGAN
SEDANG
BERAT

SELAIN KAKI (BERAT)
490
M-1-60-i
491
M-1-60-ii
492
M-1-60-iii
493
M-1-70-i
494
M-1-70-ii
495
M-1-70-iii
496
M-1-80-i
2.748.227
2.830.674
2.885.638
2.940.603
497
M-1-80-ii
4.154.757
4.279.400
4.362.495
4.445.590
498
M-1-80-iii
9.565.327
9.852.286
10.043.593
10.234.899
499
M-4-10-i
1.929.531
1.987.417
2.026.008
2.064.598
500
M-4-10-ii
2.894.297
2.981.126
3.039.012
3.096.897
501
M-4-10-iii
FRAKTUR FEMUR BERAT
5.638.903
5.808.070
5.920.848
6.033.626
502
M-4-11-i
2.411.914
2.484.271
2.532.510
2.580.748
503
M-4-11-ii
5.284.440
5.442.973
5.548.662
5.654.351
504
M-4-11-iii
9.379.758
9.661.150
9.848.745
10.036.341
505
M-4-12-i
1.929.531
1.987.417
2.026.008
2.064.598
506
M-4-12-ii
3.510.780
3.616.103
3.686.319
3.756.534
507
M-4-12-iii
6.342.290
6.532.559
6.659.405
6.786.250
508
M-4-13-i
3.213.088
3.309.480
3.373.742
3.438.004

PANGGUL RINGAN
PANGGUL SEDANG
PANGGUL BERAT
PELVIS RINGAN
PELVIS SEDANG
PELVIS BERAT
- 573 No
Kode
INA-CBG
509
M-4-13-ii
510
M-4-13-iii
511
M-4-14-i
512
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.823.828
4.968.543
5.065.019
5.161.496
9.558.131
9.844.875
10.036.038
10.227.200
3.658.265
3.768.013
3.841.178
3.914.344
M-4-14-ii
4.519.231
4.654.808
4.745.192
4.835.577
513
M-4-14-iii
OSTEOMIELITIS BERAT
6.769.321
6.972.400
7.107.787
7.243.173
514
M-4-15-i
2.171.752
2.236.905
2.280.340
2.323.775
515
M-4-15-ii
2.895.852
2.982.728
3.040.645
3.098.562
516
M-4-15-iii
8.200.507
8.446.523
8.610.533
8.774.543
517
M-4-16-i
2.411.914
2.484.271
2.532.510
2.580.748
518
M-4-16-ii
3.859.062
3.974.834
4.052.015
4.129.197
519
M-4-16-iii
6.472.612
6.666.791
6.796.243
6.925.695
2.411.914
2.484.271
2.532.510
2.580.748
3.376.680
3.477.980
3.545.513
3.613.047
4.715.712
4.857.184
4.951.498
5.045.812
2.550.147
2.626.652
2.677.655
2.728.658
3.859.062
3.974.834
4.052.015
4.129.197
4.324.901
4.454.648
4.541.146
4.627.644
1.896.069
1.952.951
1.990.873
2.028.794
3.193.588
3.289.395
3.353.267
3.417.139
6.237.313
6.424.432
6.549.179
6.673.925
1.929.531
1.987.417
2.026.008
2.064.598
2.894.297
2.981.126
3.039.012
3.096.897
3.207.563
3.303.790
3.367.941
3.432.092
1.929.531
1.987.417
2.026.008
2.064.598
2.411.914
2.484.271
2.532.510
2.580.748
5.537.616
5.703.744
5.814.497
5.925.249

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
RINGAN
SEDANG
BERAT
ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
520
M-4-17-i
521
M-4-17-ii
522
M-4-17-iii
523
M-4-18-i
524
M-4-18-ii
525
M-4-18-iii
526
M-4-19-i
527
M-4-19-ii
528
M-4-19-iii
529
M-4-20-i
530
M-4-20-ii
531
M-4-20-iii
532
M-4-21-i
533
M-4-21-ii
534
M-4-21-iii
535
N-1-01-i
4.147.845
4.272.281
4.355.237
4.438.194
536
N-1-01-ii
5.609.867
5.778.163
5.890.360
6.002.558
537
N-1-01-iii
11.894.587
12.251.424
12.489.316
12.727.208
6.266.647
6.454.646
6.579.979
6.705.312
8.475.498
8.729.763
8.899.273
9.068.783
538
N-1-11-i
539
N-1-11-ii

RINGAN
SEDANG
- 574 No
Kode
INA-CBG
540
N-1-11-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
16.520.526
17.016.142
17.346.553
17.676.963
3.097.599
3.190.527
3.252.479
3.314.431
7.891.902
8.128.659
8.286.497
8.444.335
14.383.482
14.814.987
15.102.656
15.390.326
541
N-1-12-i
542
N-1-12-ii
543
N-1-12-iii
544
N-1-20-i
4.592.880
4.730.667
4.822.525
4.914.382
545
N-1-20-ii
9.106.049
9.379.231
9.561.352
9.743.473
546
N-1-20-iii
10.416.495
10.728.990
10.937.320
11.145.649
5.464.042
5.627.963
5.737.244
5.846.525
8.303.293
8.552.392
8.718.458
8.884.524
9.558.460
9.845.214
10.036.383
10.227.552
4.923.637
5.071.346
5.169.818
5.268.291
6.674.165
6.874.390
7.007.873
7.141.357
7.762.247
7.995.114
8.150.359
8.305.604
1.916.232
1.973.719
2.012.044
2.050.369
2.809.988
2.894.288
2.950.487
3.006.687
5.616.269
5.784.757
5.897.082
6.009.407

URIN BAWAH RINGAN
URIN BAWAH SEDANG
URIN BAWAH BERAT
RINGAN
SEDANG
BERAT
GINJAL RINGAN
GINJAL SEDANG
GINJAL BERAT
547
N-1-30-i
548
N-1-30-ii
549
N-1-30-iii
550
N-1-40-i
551
N-1-40-ii
552
N-1-40-iii
553
N-4-10-i
554
N-4-10-ii
555
N-4-10-iii
556
N-4-11-i
1.607.060
1.655.271
1.687.413
1.719.554
557
N-4-11-ii
2.715.892
2.797.369
2.851.687
2.906.004
558
N-4-11-iii
3.107.867
3.201.103
3.263.260
3.325.418
559
N-4-12-i
1.553.952
1.600.571
1.631.650
1.662.729
560
N-4-12-ii
2.299.479
2.368.463
2.414.453
2.460.442
561
N-4-12-iii
3.817.891
3.932.427
4.008.785
4.085.143
562
N-4-13-i
BATU URIN RINGAN
2.214.883
2.281.330
2.325.627
2.369.925
563
N-4-13-ii
BATU URIN SEDANG
2.670.316
2.750.426
2.803.832
2.857.238
564
N-4-13-iii
BATU URIN BERAT
6.576.256
6.773.544
6.905.069
7.036.594
1.327.850
1.367.685
1.394.242
1.420.799
2.044.722
2.106.064
2.146.958
2.187.852
3.315.887
3.415.364
3.481.681
3.547.999
2.157.377
2.222.098
2.265.246
2.308.393
2.960.592
3.049.410
3.108.622
3.167.834
565
N-4-14-i
566
N-4-14-ii
567
N-4-14-iii
568
N-4-15-i
569
N-4-15-ii

(RINGAN)
(SEDANG)
(BERAT)
SALURAN URIN RINGAN
SALURAN URIN SEDANG
- 575 No
Kode
INA-CBG
570
N-4-15-iii
571
N-4-16-i
572
N-4-16-ii
573
N-4-16-iii
574
O-6-10-i
575
O-6-10-ii
576
O-6-10-iii
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
584
O-6-13-ii
585
O-6-13-iii
586
P-8-01-i
587
P-8-01-ii
588
P-8-01-iii
589
P-8-02-i
590
P-8-02-ii
591
P-8-02-iii
592
P-8-03-i
593
P-8-03-ii
594
P-8-03-iii
595
P-8-04-i
596
P-8-04-ii
597
P-8-04-iii
598
P-8-05-i
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.378.570
3.479.927
3.547.499
3.615.070
2.166.693
2.231.694
2.275.028
2.318.361
3.065.972
3.157.951
3.219.270
3.280.590
6.447.283
6.640.701
6.769.647
6.898.592
2.694.965
2.775.814
2.829.713
2.883.613
2.991.822
3.081.577
3.141.413
3.201.250
3.686.938
3.797.546
3.871.285
3.945.024
1.701.367
1.752.408
1.786.436
1.820.463
2.772.026
2.855.187
2.910.628
2.966.068
4.697.724
4.838.656
4.932.610
5.026.565
1.881.578
1.938.026
1.975.657
2.013.289
2.259.771
2.327.564
2.372.760
2.417.955
2.839.078
2.924.251
2.981.032
3.037.814
1.391.313
1.433.052
1.460.879
1.488.705
1.557.653
1.604.383
1.635.536
1.666.689
1.937.148
1.995.263
2.034.006
2.072.749
38.517.557
39.673.083
40.443.434
41.213.786
47.659.451
49.089.235
50.042.424
50.995.613
55.938.835
57.617.001
58.735.777
59.854.554
51.106.576
52.639.773
53.661.905
54.684.036
58.624.503
60.383.238
61.555.729
62.728.219
66.982.687
68.992.167
70.331.821
71.671.475
2.581.332
2.658.772
2.710.399
2.762.025
3.613.865
3.722.281
3.794.558
3.866.836
5.692.657
5.863.437
5.977.290
6.091.143
25.246.210
26.003.596
26.508.520
27.013.444
32.764.137
33.747.061
34.402.344
35.057.626
46.975.525
48.384.791
49.324.301
50.263.812
13.728.070
14.139.912
14.414.474
14.689.035

SALURAN URIN BERAT
RINGAN
SEDANG
BERAT
&KURET RINGAN
KURET SEDANG
KURET BERAT

- 576 No
Kode
INA-CBG
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii
603
P-8-06-iii
604
P-8-07-i
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
614
P-8-11-ii
615
P-8-11-iii
616
P-8-12-i
617
P-8-12-ii
618
P-8-12-iii
619
P-8-13-i
620
P-8-13-ii
621
P-8-13-iii
622
P-8-14-i
623
P-8-14-ii
624
P-8-14-iii
625
P-8-15-i
626
P-8-15-ii
Deskripsi (INA-CBG)
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
RINGAN
SEDANG
BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
ASPIRASI RINGAN
ASPIRASI SEDANG
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
19.457.689
20.041.419
20.430.573
20.819.727
28.668.292
29.528.341
30.101.707
30.675.073
2.065.066
2.127.018
2.168.319
2.209.620
5.690.578
5.861.296
5.975.107
6.088.919
10.585.125
10.902.679
11.114.381
11.326.084
3.648.227
3.757.674
3.830.638
3.903.603
10.132.408
10.436.380
10.639.028
10.841.676
13.422.928
13.825.615
14.094.074
14.362.533
2.868.045
2.954.086
3.011.447
3.068.808
4.071.593
4.193.741
4.275.173
4.356.605
5.747.839
5.920.275
6.035.231
6.150.188
1.779.332
1.832.712
1.868.298
1.903.885
2.577.621
2.654.950
2.706.502
2.758.054
5.060.630
5.212.449
5.313.661
5.414.874
2.155.335
2.219.995
2.263.102
2.306.208
10.669.036
10.989.107
11.202.488
11.415.869
10.892.554
11.219.331
11.437.182
11.655.033
2.364.226
2.435.152
2.482.437
2.529.721
3.675.960
3.786.239
3.859.758
3.933.277
4.336.856
4.466.961
4.553.698
4.640.435
1.221.959
1.258.618
1.283.057
1.307.496
2.261.226
2.329.063
2.374.287
2.419.512
3.381.905
3.483.362
3.551.000
3.618.639
2.232.647
2.299.626
2.344.279
2.388.932
4.558.432
4.695.185
4.786.354
4.877.523
5.000.583
5.150.601
5.250.613
5.350.624
1.679.020
1.729.390
1.762.971
1.796.551
3.355.919
3.456.597
3.523.715
3.590.834
- 577 No
Kode
INA-CBG
627
P-8-15-iii
628
P-8-16-i
629
P-8-16-ii
630
P-8-16-iii
631
P-8-17-i
632
P-8-17-ii
633
P-8-17-iii
634
S-4-10-i
635
S-4-10-ii
636
S-4-10-iii
637
S-4-11-i
638
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.942.047
4.060.308
4.139.149
4.217.990
1.519.910
1.565.507
1.595.905
1.626.303
2.156.057
2.220.739
2.263.860
2.306.981
2.798.668
2.882.628
2.938.601
2.994.575
1.001.316
1.031.355
1.051.382
1.071.408
3.332.082
3.432.045
3.498.686
3.565.328
6.725.596
6.927.363
7.061.875
7.196.387
1.532.986
1.578.975
1.609.635
1.640.295
1.916.232
1.973.719
2.012.044
2.050.369
2.490.773
2.565.496
2.615.312
2.665.127
958.116
986.860
1.006.022
1.025.184
S-4-11-ii
1.532.986
1.578.975
1.609.635
1.640.295
639
S-4-11-iii
2.359.227
2.430.004
2.477.189
2.524.373
640
S-4-12-i
1.149.739
1.184.232
1.207.226
1.230.221
641
S-4-12-ii
1.532.986
1.578.975
1.609.635
1.640.295
642
S-4-12-iii
2.994.043
3.083.864
3.143.745
3.203.626
1.532.986
1.578.975
1.609.635
1.640.295
2.709.975
2.791.275
2.845.474
2.899.674
5.517.854
5.683.390
5.793.747
5.904.104
934.020
962.041
980.721
999.402
1.984.172
2.043.697
2.083.381
2.123.064
3.762.697
3.875.578
3.950.832
4.026.086
706.408
727.600
741.728
755.857
1.333.233
1.373.230
1.399.894
1.426.559
1.726.846
1.778.651
1.813.188
1.847.725

ASPIRASI BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT

PASIEN RINGAN
PASIEN SEDANG
PASIEN BERAT
643
S-4-13-i
644
S-4-13-ii
645
S-4-13-iii
646
S-4-14-i
647
S-4-14-ii
648
S-4-14-iii
649
S-4-15-i
650
S-4-15-ii
651
S-4-15-iii
652
S-4-16-i
LUKA BAKAR RINGAN
2.682.725
2.763.207
2.816.862
2.870.516
653
S-4-16-ii
LUKA BAKAR SEDANG
4.149.328
4.273.808
4.356.794
4.439.781
654
S-4-16-iii
LUKA BAKAR BERAT
7.409.269
7.631.547
7.779.733
7.927.918
655
S-4-17-i
1.566.567
1.613.564
1.644.895
1.676.227
656
S-4-17-ii
1.916.232
1.973.719
2.012.044
2.050.369
657
S-4-17-iii
3.124.795
3.218.539
3.281.035
3.343.531
658
T-1-10-i
1.617.130
1.665.643
1.697.986
1.730.329

- 578 No
Kode
INA-CBG
659
T-1-10-ii
660
T-1-10-iii
661
T-4-10-i
662
T-4-10-ii
663
T-4-10-iii
664
T-4-11-i
665
T-4-11-ii
666
T-4-11-iii
667
T-4-12-i
668
T-4-12-ii
669
T-4-12-iii
670
U-1-10-i
671
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.171.695
2.236.846
2.280.280
2.323.714
3.951.022
4.069.552
4.148.573
4.227.593
645.930
665.308
678.226
691.145
1.230.999
1.267.929
1.292.549
1.317.169
1.789.538
1.843.224
1.879.015
1.914.806
699.557
720.544
734.535
748.526
1.100.903
1.133.931
1.155.949
1.177.967
1.773.231
1.826.428
1.861.893
1.897.357
1.341.363
1.381.604
1.408.431
1.435.258
2.027.396
2.088.218
2.128.766
2.169.314
3.153.899
3.248.516
3.311.594
3.374.672
1.427.758
1.470.590
1.499.146
1.527.701
U-1-10-ii
2.913.427
3.000.830
3.059.099
3.117.367
672
U-1-10-iii
12.580.768
12.958.191
13.209.806
13.461.421
673
U-1-11-i
6.195.197
6.381.053
6.504.957
6.628.861
674
U-1-11-ii
8.260.263
8.508.071
8.673.276
8.838.482
675
U-1-11-iii
15.198.224
15.654.171
15.958.135
16.262.100
676
U-1-12-i
4.146.119
4.270.503
4.353.425
4.436.347
677
U-1-12-ii
9.292.796
9.571.580
9.757.436
9.943.292
678
U-1-12-iii
12.066.872
12.428.878
12.670.215
12.911.553
679
U-1-13-i
4.130.132
4.254.036
4.336.638
4.419.241
680
U-1-13-ii
5.103.218
5.256.314
5.358.379
5.460.443
681
U-1-13-iii
8.985.619
9.255.187
9.434.900
9.614.612
682
U-1-14-i
2.495.672
2.570.542
2.620.456
2.670.369
683
U-1-14-ii
3.062.691
3.154.572
3.215.826
3.277.080
684
U-1-14-iii
3.629.375
3.738.257
3.810.844
3.883.432
685
U-1-15-i
1.465.803
1.509.777
1.539.093
1.568.410
686
U-1-15-ii
2.082.804
2.145.288
2.186.944
2.228.600
687
U-1-15-iii
4.104.249
4.227.377
4.309.462
4.391.547
3.791.395
3.905.137
3.980.964
4.056.792
6.748.683
6.951.143
7.086.117
7.221.090
688
U-1-20-i
689
U-1-20-ii

DOKTER RINGAN
DOKTER SEDANG
DOKTER BERAT

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)


- 579 No
Kode
INA-CBG
690
U-1-20-iii

691
U-1-30-i
692
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
15.202.952
15.659.040
15.963.099
16.267.158
3.252.355
3.349.926
3.414.973
3.480.020
U-1-30-ii
4.390.680
4.522.400
4.610.214
4.698.027
693
U-1-30-iii
8.260.263
8.508.071
8.673.276
8.838.482
694
U-4-10-i
3.027.400
3.118.222
3.178.770
3.239.318
695
U-4-10-ii
7.589.055
7.816.727
7.968.508
8.120.289
696
U-4-10-iii
11.070.779
11.402.902
11.624.318
11.845.733
697
U-4-11-i
1.532.986
1.578.975
1.609.635
1.640.295
698
U-4-11-ii
2.299.479
2.368.463
2.414.453
2.460.442
699
U-4-11-iii
3.482.708
3.587.189
3.656.843
3.726.497
700
U-4-12-i
1.532.986
1.578.975
1.609.635
1.640.295
701
U-4-12-ii
1.957.121
2.015.834
2.054.977
2.094.119
702
U-4-12-iii
3.111.733
3.205.085
3.267.319
3.329.554
703
U-4-13-i
1.532.986
1.578.975
1.609.635
1.640.295
704
U-4-13-ii
1.750.866
1.803.392
1.838.409
1.873.427
705
U-4-13-iii
2.177.102
2.242.415
2.285.957
2.329.499
706
U-4-14-i
1.916.232
1.973.719
2.012.044
2.050.369
707
U-4-14-ii
2.299.479
2.368.463
2.414.453
2.460.442
708
U-4-14-iii
3.852.026
3.967.587
4.044.627
4.121.668
709
U-4-15-i
1.532.986
1.578.975
1.609.635
1.640.295
710
U-4-15-ii
1.916.232
1.973.719
2.012.044
2.050.369
711
U-4-15-iii
2.683.245
2.763.743
2.817.408
2.871.073
712
V-1-10-i
4.481.426
4.615.869
4.705.497
4.795.126
713
V-1-10-ii
5.162.664
5.317.544
5.420.798
5.524.051
714
V-1-10-iii
9.809.062
10.103.334
10.299.516
10.495.697
715
V-1-11-i
5.162.664
5.317.544
5.420.798
5.524.051
716
V-1-11-ii
5.761.620
5.934.469
6.049.701
6.164.934
717
V-1-11-iii
8.532.077
8.788.040
8.958.681
9.129.323
3.053.508
3.145.113
3.206.183
3.267.253
11.448.951
11.792.420
12.021.399
12.250.378
12.875.847
13.262.122
13.519.639
13.777.156
4.628.128
4.766.971
4.859.534
4.952.097
8.794.771
9.058.614
9.234.509
9.410.405
718
V-1-12-i
719
V-1-12-ii
720
V-1-12-iii
721
V-1-13-i
722
V-1-13-ii

DAN TELINGA RINGAN
DAN TELINGA SEDANG
DAN TELINGA BERAT


KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

- 580 No
Kode
INA-CBG
723
V-1-13-iii
724
V-1-14-i
725
V-1-14-ii
726
V-1-14-iii
727
V-1-15-i
728
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
12.390.395
12.762.107
13.009.914
13.257.722
5.579.262
5.746.639
5.858.225
5.969.810
8.114.558
8.357.995
8.520.286
8.682.577
11.030.561
11.361.478
11.582.089
11.802.700
2.630.311
2.709.221
2.761.827
2.814.433
V-1-15-ii
4.834.006
4.979.026
5.075.706
5.172.387
729
V-1-15-iii
8.042.762
8.284.045
8.444.900
8.605.756
730
V-4-10-i
4.235.465
4.362.529
4.447.238
4.531.948
731
V-4-10-ii
5.470.609
5.634.727
5.744.140
5.853.552
732
V-4-10-iii
10.455.294
10.768.953
10.978.059
11.187.165
733
V-4-11-i
2.153.893
2.218.509
2.261.587
2.304.665
734
V-4-11-ii
3.147.181
3.241.597
3.304.540
3.367.484
735
V-4-11-iii
5.192.641
5.348.420
5.452.273
5.556.125
736
W-1-01-i
6.333.499
6.523.504
6.650.174
6.776.844
737
W-1-01-ii
7.628.399
7.857.251
8.009.819
8.162.387
738
W-1-01-iii
16.849.618
17.355.107
17.692.099
18.029.092
739
W-1-10-i
1.763.872
1.816.788
1.852.065
1.887.343
740
W-1-10-ii
3.291.674
3.390.425
3.456.258
3.522.092
741
W-1-10-iii
5.384.135
5.545.659
5.653.342
5.761.024
742
W-1-11-i
1.832.076
1.887.039
1.923.680
1.960.322
743
W-1-11-ii
3.533.391
3.639.393
3.710.061
3.780.728
744
W-1-11-iii
6.195.197
6.381.053
6.504.957
6.628.861
745
W-1-12-i
1.664.717
1.714.658
1.747.952
1.781.247
746
W-1-12-ii
1.892.751
1.949.533
1.987.388
2.025.244
747
W-1-12-iii
2.907.504
2.994.729
3.052.879
3.111.029
748
W-1-13-i
1.809.285
1.863.563
1.899.749
1.935.934
749
W-1-13-ii
1.964.362
2.023.292
2.062.580
2.101.867
750
W-1-13-iii
2.638.500
2.717.655
2.770.425
2.823.195
751
W-1-20-i
5.398.768
5.560.731
5.668.706
5.776.681
752
W-1-20-ii
7.594.177
7.822.002
7.973.885
8.125.769
753
W-1-20-iii
9.292.796
9.571.580
9.757.436
9.943.292
W-1-30-i

RINGAN
2.947.186
3.035.601
3.094.545
3.153.489
754

NON KOMPLEK (BERAT)

RINGAN
SEDANG
BERAT

SERVIK RINGAN
SERVIK SEDANG
SERVIK BERAT
ENDOSKOP RINGAN
ENDOSKOP SEDANG
ENDOSKOP BERAT
- 581 No
Kode
INA-CBG
755
W-1-30-ii
756
W-1-30-iii
757
W-4-10-i
758
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.700.914
4.841.941
4.935.959
5.029.978
12.500.886
12.875.913
13.125.931
13.375.948
2.197.862
2.263.798
2.307.755
2.351.713
W-4-10-ii
2.970.657
3.059.777
3.119.190
3.178.603
759
W-4-10-iii
6.131.944
6.315.902
6.438.541
6.561.180
760
W-4-11-i
1.916.232
1.973.719
2.012.044
2.050.369
761
W-4-11-ii
3.065.972
3.157.951
3.219.270
3.280.590
762
W-4-11-iii
3.726.064
3.837.846
3.912.368
3.986.889
763
W-4-12-i
1.532.986
1.578.975
1.609.635
1.640.295
764
W-4-12-ii
2.133.181
2.197.177
2.239.840
2.282.504
765
W-4-12-iii
2.573.589
2.650.796
2.702.268
2.753.740
766
W-4-13-i
ABORTUS RINGAN
840.708
865.929
882.743
899.557
767
W-4-13-ii
ABORTUS SEDANG
1.149.739
1.184.232
1.207.226
1.230.221
768
W-4-13-iii
ABORTUS BERAT
1.532.986
1.578.975
1.609.635
1.640.295
769
W-4-14-i
1.149.739
1.184.232
1.207.226
1.230.221
770
W-4-14-ii
1.532.986
1.578.975
1.609.635
1.640.295
771
W-4-14-iii
1.860.721
1.916.542
1.953.757
1.990.971
772
W-4-15-i
1.049.957
1.081.456
1.102.455
1.123.454
773
W-4-15-ii
1.167.752
1.202.785
1.226.140
1.249.495
774
W-4-15-iii
1.563.359
1.610.260
1.641.527
1.672.794
775
W-4-16-i
1.149.739
1.184.232
1.207.226
1.230.221
776
W-4-16-ii
1.668.913
1.718.981
1.752.359
1.785.737
777
W-4-16-iii
2.126.994
2.190.804
2.233.344
2.275.883
778
W-4-17-i
1.028.391
1.059.243
1.079.811
1.100.378
779
W-4-17-ii
1.532.986
1.578.975
1.609.635
1.640.295
780
W-4-17-iii
2.900.104
2.987.108
3.045.110
3.103.112
781
Z-4-10-i
REHABILITASI RINGAN
2.630.422
2.709.335
2.761.943
2.814.552
782
Z-4-10-ii
REHABILITASI SEDANG
3.491.506
3.596.251
3.666.081
3.735.911
783
Z-4-10-iii
REHABILITASI BERAT
4.960.017
5.108.818
5.208.018
5.307.218
784
Z-4-11-i
2.514.500
2.589.935
2.640.225
2.690.515
785
Z-4-11-ii
3.026.902
3.117.709
3.178.247
3.238.785
786
Z-4-11-iii
4.732.145
4.874.110
4.968.752
5.063.395
1.149.739
1.184.232
1.207.226
1.230.221
2.565.409
2.642.372
2.693.680
2.744.988
3.260.229
3.358.036
3.423.241
3.488.445
787
Z-4-12-i
788
Z-4-12-ii
789
Z-4-12-iii

SEDANG
BERAT


- 582 b. RawatJalan
No
Kode
INA-CBG
B-2-10-0
B-211-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
775.006
798.256
813.756
829.256
1.005.304
1.035.463
1.055.569
1.075.675
1.869.494
1.925.579
1.962.969
2.000.359
1.544.956
1.591.304
1.622.204
1.653.103
1.290.677
1.329.398
1.355.211
1.381.025
452.517
466.093
475.143
484.193
1.009.054
1.039.326
1.059.507
1.079.688

207.327
213.547
217.694
221.840
C-3-10-0
565.560
582.527
593.838
605.149
10
C-3-11-0

KANDUNG KEMIH
894.454
921.288
939.177
957.066
11
C-3-12-0
202.771
208.854
212.909
216.965
196.904
202.812
206.750
210.688
1.676.251
1.726.538
1.760.063
1.793.588
1.536.351
1.582.441
1.613.168
1.643.895

LAPAROSKOPI
PANKREAS
LAPAROSKOPI
EMPEDU

OVARIUM
GASTROINTESTINAL
GINJAL ATAU PROSTAT
12
C-3-13-0
13
C-3-14-0
14
C-3-15-0
15
C-3-16-0
348.407
358.860
365.828
372.796
16
C-3-17-0

LEHER
231.123
238.057
242.679
247.302
17
C-3-18-0
102.470
105.544
107.594
109.643
18
C-3-19-0

MYELOMA ATAU TESTIS
144.913
149.261
152.159
155.057
19
C-3-20-0
2.885.957
2.972.536
3.030.255
3.087.974
20
C-3-21-0
165.372
170.333
173.641
176.948
21
C-3-22-0
726.072
747.854
762.376
776.897
22
C-3-23-0
117.608
121.136
123.488
125.840
23
D-2-10-0

TULANG
996.390
1.026.282
1.046.209
1.066.137
24
D-2-11-0
PROSEDUR LIMPA
1.247.650
1.285.080
1.310.033
1.334.986
25
D-2-21-0
1.046.425
1.077.818
1.098.747
1.119.675
26
D-2-22-0
229.659
236.549
241.142
245.735
27
D-3-10-0
166.348
171.338
174.665
177.992
28
D-3-11-0
431.886
444.843
453.481
462.118
29
E-2-10-0
256.192
263.877
269.001
274.125
30
E-2-21-0
185.730
191.302
195.017
198.731
31
E-2-22-0
185.730
191.302
195.017
198.731

TYMUS
TYMUS
TULANG
PEMBENTUK DARAH
PARATIROID
THYROGLOSSAL
- 583 No
Kode
INA-CBG
32
E-3-10-0
33
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

ENDOKRIN
215.992
222.472
226.792
231.112
F-3-10-0
TERAPI SHOCK
301.302
310.341
316.367
322.393
34
F-5-10-0
369.193
380.268
387.652
395.036
35
F-5-11-0
TERAPI KELOMPOK
243.449
250.752
255.621
260.490
36
F-5-12-0
311.534
320.880
327.110
333.341
37
F-5-13-0
263.848
271.764
277.041
282.318
38
F-5-14-0
177.007
182.317
185.857
189.397
39
F-5-15-0
166.055
171.037
174.358
177.679
40
F-5-16-0
172.963
178.151
181.611
185.070
41
G-2-10-0
145.648
150.017
152.930
155.843
42
G-2-11-0
1.262.536
1.300.412
1.325.663
1.350.914
43
G-2-12-0

EKSTRAKRANIAL
1.829.726
1.884.618
1.921.212
1.957.807
44
G-2-13-0
463.445
477.348
486.617
495.886
45
G-2-21-0
818.668
843.228
859.601
875.975
46
G-2-22-0
743.011
765.301
780.161
795.022
47
G-2-31-0
1.265.835
1.303.810
1.329.127
1.354.444
48
G-2-32-0
648.866
668.332
681.309
694.287
49
G-3-10-0
257.539
265.265
270.416
275.567
50
G-3-11-0
332.208
342.174
348.818
355.462
51
G-3-12-0
544.328
560.658
571.544
582.431
52
G-3-13-0
544.390
560.722
571.610
582.497
53
H-2-21-0
714.431
735.864
750.153
764.441
54
H-2-22-0
185.730
191.302
195.017
198.731
55
H-2-23-0
185.730
191.302
195.017
198.731
56
H-2-31-0
1.183.396
1.218.898
1.242.565
1.266.233
57
H-2-32-0
123.164
126.859
129.322
131.785
58
H-2-33-0
185.730
191.302
195.017
198.731
59
H-2-34-0
530.900
546.827
557.445
568.063
60
H-2-35-0
174.944
180.192
183.691
187.190
61
H-2-36-0
944.305
972.634
991.520
1.010.406
62
H-2-37-0

1.005.254
1.035.412
1.055.517
1.075.622
63
H-3-10-0
349.755
360.248
367.243
374.238
64
H-3-11-0
183.932
189.450
193.129
196.808

AKUT
MENTAL
PROSEDUR KRANIOTOMI

MATA
MATA
MATA
MATA
MATA
- 584 No
Kode
INA-CBG
65
H-3-12-0
66
H-3-13-0
67
I-2-11-0
68
I-2-12-0
69
I-2-13-0
70
I-2-14-0
71
I-2-15-0
Deskripsi (INA-CBG)
MATA
TORASIK
ABDOMEN
PENGGANTIAN ALAT
DARAH VENA
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
192.035
197.796
201.636
205.477
186.454
192.048
195.777
199.506
2.150.214
2.214.720
2.257.725
2.300.729
1.511.835
1.557.190
1.587.427
1.617.663
1.921.451
1.979.095
2.017.524
2.055.953
3.400.560
3.502.576
3.570.588
3.638.599
204.503
210.638
214.728
218.818
2.147.884
2.212.320
2.255.278
2.298.235
708.096
729.338
743.500
757.662
72
I-2-16-0
73
I-2-17-0
74
I-2-21-0
1.657.861
1.707.597
1.740.754
1.773.911
75
I-2-22-0
1.561.166
1.608.001
1.639.225
1.670.448
76
I-2-23-0
319.488
329.073
335.462
341.852
77
I-2-31-0
2.484.766
2.559.309
2.609.004
2.658.700
78
I-2-32-0
3.249.197
3.346.672
3.411.656
3.476.640
79
I-2-41-0
2.178.626
2.243.985
2.287.558
2.331.130
80
I-2-42-0

LAIN
2.533.013
2.609.004
2.659.664
2.710.324
81
I-3-10-0
PROSEDUR RESUSITASI
321.544
331.190
337.621
344.052
82
I-3-11-0
169.710
174.801
178.195
181.590
83
I-3-12-0
986.290
1.015.879
1.035.605
1.055.331
84
I-3-13-0
323.936
333.654
340.133
346.611
85
I-3-14-0
207.632
213.861
218.013
222.166
183.932
189.450
193.129
196.808
1.138.791
1.172.955
1.195.730
1.218.506
183.573
189.080
192.752
196.423
925.093
952.845
971.347
989.849
1.199.928
1.235.926
1.259.924
1.283.923

PACU JANTUNG

KARDIOVASKULAR
PERNAFASAN
PENDEK
86
I-3-15-0
87
J-2-10-0
88
J-2-21-0
89
J-2-22-0
90
J-2-31-0
91
J-2-32-0
892.945
919.734
937.593
955.452
92
J-3-10-0
185.730
191.302
195.017
198.731
93
J-3-11-0

PADA DADA
524.840
540.586
551.082
561.579
94
J-3-12-0
202.771
208.854
212.909
216.965
95
J-3-13-0
298.428
307.381
313.350
319.318
96
J-3-14-0
316.814
326.318
332.655
338.991
- 585 No
Kode
INA-CBG
97
J-3-15-0
98
J-3-16-0
99
J-3-17-0
100
K-2-10-0
101
K-2-11-0
102
K-2-12-0

103
K-2-13-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
277.821
286.155
291.712
297.268
316.814
326.318
332.655
338.991
185.730
191.302
195.017
198.731
534.595
550.633
561.325
572.017
1.141.578
1.175.826
1.198.657
1.221.489
876.309
902.598
920.124
937.650
1.426.240
1.469.027
1.497.552
1.526.077
185.730
191.302
195.017
198.731
185.730
191.302
195.017
198.731
2.387.075
2.458.687
2.506.429
2.554.170
802.652
826.732
842.785
858.838
185.730
191.302
195.017
198.731

PERNAFASAN
KECIL

FEMORALIS
USUS BESAR
ATAS
ATAS
104
K-2-14-0
105
K-2-21-0
106
K-2-22-0
107
K-2-31-0
108
K-2-32-0
109
K-2-41-0
884.138
910.662
928.345
946.027
110
K-2-42-0

252.609
260.187
265.240
270.292
111
K-2-51-0
585.883
603.460
615.177
626.895
112
K-2-52-0
319.488
329.073
335.462
341.852
113
K-2-53-0
185.730
191.302
195.017
198.731
114
K-3-10-0

GASTROINTESTINAL
353.432
364.035
371.104
378.172
115
K-3-11-0
212.482
218.856
223.106
227.355
116
K-3-12-0
215.483
221.948
226.257
230.567
117
K-3-13-0
185.730
191.302
195.017
198.731
497.761
512.694
522.649
532.604
240.376
247.587
252.394
257.202
318.513
328.068
334.439
340.809
1.095.060
1.127.911
1.149.813
1.171.714
701.925
722.983
737.022
751.060
316.814
326.318
332.655
338.991
319.488
329.073
335.462
341.852

GASTROINTESTINAL
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
118
K-3-14-0
119
K-3-15-0
120
K-3-16-0
121
L-2-21-0
122
L-2-22-0
123
L-2-31-0
124
L-2-32-0
125
L-2-41-0
956.669
985.369
1.004.502
1.023.636
126
L-2-42-0

214.565
221.002
225.294
229.585
127
L-2-51-0
1.432.283
1.475.252
1.503.897
1.532.543
L-2-52-0

1.095.744
1.128.616
1.150.531
1.172.446
128
- 586 No
Kode
INA-CBG
129
L-2-53-0
130
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

185.730
191.302
195.017
198.731
L-3-10-0
252.609
260.187
265.240
270.292
131
L-3-11-0
245.301
252.660
257.566
262.472
132
L-3-12-0
186.820
192.425
196.161
199.897
133
M-2-10-0
1.465.330
1.509.290
1.538.597
1.567.903
134
M-2-21-0
1.354.908
1.395.555
1.422.653
1.449.752
135
M-2-22-0
329.860
339.756
346.353
352.950
136
M-2-31-0
PROSEDUR BUNION
822.971
847.660
864.119
880.578
137
M-2-32-0
260.810
268.634
273.850
279.067
138
M-2-41-0

TULANG
260.810
268.634
273.850
279.067
139
M-2-42-0
89.882
92.579
94.376
96.174
140
M-2-51-0
191.760
197.513
201.348
205.183
141
M-2-52-0
191.760
197.513
201.348
205.183
142
M-2-61-0
PROSEDUR ARTROSKOPI
939.915
968.113
986.911
1.005.709
143
M-2-62-0
191.760
197.513
201.348
205.183
945.000
973.350
992.250
1.011.150
1.288.785
1.327.448
1.353.224
1.379.000
191.760
197.513
201.348
205.183
951.462
980.006
999.035
1.018.064
918.201
945.747
964.111
982.475

DAN WAJAH
PAHA
PAHA

TULANG
WAJAH
WAJAH
BAWAH
BAWAH
144
M-2-63-0
145
M-2-64-0
146
M-2-65-0
147
M-2-71-0
148
M-2-72-0
149
M-2-81-0
1.369.234
1.410.311
1.437.695
1.465.080
150
M-2-82-0
994.660
1.024.500
1.044.393
1.064.287
151
M-2-83-0
191.760
197.513
201.348
205.183
152
M-2-84-0
191.760
197.513
201.348
205.183
153
M-3-10-0
547.320
563.739
574.686
585.632
154
M-3-11-0
303.455
312.559
318.628
324.697
155
M-3-12-0
686.241
706.828
720.553
734.278
156
M-3-13-0
223.733
230.445
234.920
239.394
157
M-3-14-0

TERTUTUP
382.398
393.870
401.517
409.165
158
M-3-15-0
168.470
173.524
176.893
180.262
159
M-3-16-0

191.760
197.513
201.348
205.183
160
M-3-17-0
209.354
215.634
219.822
224.009
161
N-2-11-0
2.453.678
2.527.288
2.576.362
2.625.435

PERGELANGAN TANGAN
PERGELANGAN TANGAN
MUSKULOSKELETAL
SKELETAL
- 587 No
Kode
INA-CBG
162
N-2-12-0
163
N-2-21-0
164
N-2-22-0
165
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.419.428
1.462.011
1.490.400
1.518.788
1.411.946
1.454.305
1.482.544
1.510.783
319.488
329.073
335.462
341.852
N-2-23-0
319.488
329.073
335.462
341.852
166
N-2-24-0
1.032.478
1.063.452
1.084.102
1.104.751
167
N-2-31-0
869.179
895.254
912.638
930.022
168
N-2-32-0
319.488
329.073
335.462
341.852
169
N-2-41-0
319.488
329.073
335.462
341.852
170
N-2-42-0
540.315
556.525
567.331
578.138
171
N-3-10-0
319.488
329.073
335.462
341.852
172
N-3-11-0
370.172
381.278
388.681
396.085
173
N-3-12-0
286.049
294.630
300.351
306.072
174
N-3-13-0
319.488
329.073
335.462
341.852
175
N-3-14-0
274.902
283.149
288.647
294.145
176
N-3-15-0
704.918
726.066
740.164
754.262
177
O-7-10-0
117.691
121.222
123.575
125.929
178
O-7-11-0
648.155
667.600
680.563
693.526
179
O-7-12-0
236.015
243.096
247.816
252.536
180
O-7-13-0
131.167
135.102
137.725
140.348
181
P-9-10-0
174.944
180.192
183.691
187.190
182
P-9-11-0
174.944
180.192
183.691
187.190
183
P-9-12-0
174.944
180.192
183.691
187.190
184
P-9-13-0
174.944
180.192
183.691
187.190
185
P-9-14-0
174.944
180.192
183.691
187.190
186
P-9-15-0
111.513
114.858
117.088
119.319
187
P-9-16-0
174.944
180.192
183.691
187.190
188
P-9-17-0
174.191
179.417
182.901
186.385
189
Q-5-10-0
228.007
234.848
239.408
243.968
190
Q-5-11-0
170.885
176.012
179.430
182.847
191
Q-5-12-0
GIGI
150.614
155.132
158.144
161.157
192
Q-5-13-0
MEDICAL CHECK-UP
114.460
117.894
120.183
122.472
193
Q-5-14-0
125.943
129.722
132.240
134.759


DAN URETHRA
URETHRA
TRANSURETHRA
TRANSURETHRA
SALURAN KEMIH
KEMIH
KEMIH
PROSEDUR DIALISIS
CAESAR
VAGINAL/JALAN LAHIR

ASPIRASI
- 588 No
Kode
INA-CBG
194
Q-5-15-0
195
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
86.611
89.209
90.942
92.674
Q-5-16-0
VAKSINASI
97.891
100.827
102.785
104.743
196
Q-5-17-0
PASANG INFUS
84.673
87.213
88.906
90.600
197
Q-5-18-0
159.381
164.162
167.350
170.537
198
Q-5-19-0
178.178
183.523
187.087
190.651
199
Q-5-20-0
ABORSI MENGANCAM
119.427
123.010
125.398
127.787
200
Q-5-21-0
ABORSI
117.800
121.334
123.690
126.046
201
Q-5-22-0
125.943
129.722
132.240
134.759
202
Q-5-23-0
154.188
158.813
161.897
164.981
203
Q-5-24-0
105.308
108.467
110.573
112.680
204
Q-5-25-0
164.226
169.153
172.437
175.722
205
Q-5-26-0
BRONKIAL AKUT
232.450
239.424
244.073
248.722
206
Q-5-27-0
165.423
170.386
173.694
177.003
207
Q-5-28-0
134.236
138.264
140.948
143.633
208
Q-5-29-0

JANTUNG LAIN-LAIN
380.046
391.447
399.048
406.649
209
Q-5-30-0
440.432
453.645
462.453
471.262
210
Q-5-31-0
FRAKTUR
157.128
161.842
164.985
168.127
211
Q-5-32-0
SALURAN KEMIH AKUT
181.990
187.450
191.090
194.729
212
Q-5-33-0
HEMATOLOGI AKUT
190.543
196.259
200.070
203.881
213
Q-5-34-0
INFEKSI VIRUS HIV
270.680
278.800
284.214
289.627
214
Q-5-35-0
INFEKSI AKUT
306.943
316.152
322.291
328.430
215
Q-5-36-0
357.456
368.179
375.328
382.477
216
Q-5-37-0

SHOCK
182.321
187.790
191.437
195.083
217
Q-5-38-0
PARU AKUT
243.130
250.424
255.287
260.150
218
Q-5-39-0
155.586
160.253
163.365
166.477
219
Q-5-40-0
152.654
157.234
160.287
163.340
220
Q-5-41-0
211.328
217.668
221.895
226.121
221
Q-5-42-0
165.690
170.660
173.974
177.288
222
Q-5-43-0
238.603
245.761
250.533
255.305
223
Q-5-44-0
194.733
200.575
204.470
208.364
224
T-2-10-0

TERAPI DETOKSIKASI
101.005
104.035
106.055
108.075
225
U-2-10-0
1.348.022
1.388.463
1.415.423
1.442.384
226
U-2-11-0

LEHER
1.602.274
1.650.343
1.682.388
1.714.434
227
U-2-12-0
176.292
181.581
185.107
188.632
- 589 No
Kode
INA-CBG
228
U-2-13-0
229
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
231.123
238.057
242.679
247.302
U-2-14-0
429.322
442.202
450.788
459.375
230
U-2-15-0
243.931
251.249
256.128
261.007
231
U-2-21-0
284.142
292.666
298.349
304.032
232
U-2-22-0
548.985
565.455
576.434
587.414
233
U-2-23-0
719.348
740.928
755.315
769.702
234
U-2-24-0
606.254
624.442
636.567
648.692
235
U-2-25-0
231.123
238.057
242.679
247.302
236
U-2-31-0
185.730
191.302
195.017
198.731
237
U-2-32-0
231.123
238.057
242.679
247.302
238
U-3-10-0
220.966
227.595
232.014
236.434
239
U-3-11-0
234.597
241.635
246.327
251.019
240
U-3-12-0
103.738
106.851
108.925
111.000
241
U-3-13-0
228.025
234.866
239.427
243.987
242
U-3-14-0
209.508
215.793
219.984
224.174
243
U-3-15-0
182.710
188.191
191.845
195.499
244
U-3-16-0
PROSEDUR PADA GIGI
206.063
212.245
216.367
220.488
245
V-2-10-0

PROSTAT
2.010.387
2.070.699
2.110.907
2.151.114
246
V-2-11-0
226.721
233.522
238.057
242.591
723.497
745.202
759.672
774.142
319.488
329.073
335.462
341.852
319.488
329.073
335.462
341.852

(RHINOPLASTY)

RONGGA HIDUNG
TENGGOROKAN
PROSEDUR PADA PENIS

SKROTUM
SKROTUM
TRANSURETHRAL
247
V-2-12-0
248
V-2-13-0
249
V-2-14-0
250
V-2-15-0
SIRKUMSISI/SUNAT
174.944
180.192
183.691
187.190
251
V-3-10-0
364.857
375.802
383.100
390.397
252
V-3-11-0
771.861
795.017
810.454
825.891
253
V-3-12-0
445.616
458.984
467.897
476.809
254
W-2-10-0
163.172
168.067
171.331
174.594
255
W-2-11-0
417.007
429.518
437.858
446.198
256
W-2-12-0
771.861
795.017
810.454
825.891
257
W-2-13-0
123.793
127.507
129.982
132.458
258
W-2-21-0
1.602.020
1.650.081
1.682.121
1.714.162
259
W-2-22-0
168.470
173.524
176.893
180.262

PROSEDUR ABORSI
RAHIM & LEHER RAHIM
TERHALANG/TERGANGGU
TERHALANG/TERGANGGU
PANGGUL TERBUKA
PANGGUL TERBUKA
- 590 No
Kode
INA-CBG
260
W-2-23-0
Deskripsi (INA-CBG)
JALAN LAHIR
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
544.514
560.849
571.739
582.630
1.787.473
1.841.097
1.876.846
1.912.596
1.253.636
1.291.245
1.316.317
1.341.390
261
W-2-31-0
262
W-2-32-0
263
W-2-33-0
532.812
548.796
559.452
570.109
264
W-2-34-0
181.219
186.655
190.280
193.904
265
W-3-10-0
440.431
453.644
462.453
471.262
266
W-3-11-0
352.068
362.630
369.672
376.713
267
W-3-12-0
163.172
168.067
171.331
174.594
268
Z-3-10-0
1.847.327
1.902.747
1.939.693
1.976.640
269
Z-3-11-0

EMPEDU
1.411.946
1.454.305
1.482.544
1.510.783
270
Z-3-12-0
235.761
242.834
247.549
252.264
271
Z-3-13-0

LAIN-LAIN
1.438.678
1.481.838
1.510.611
1.539.385
272
Z-3-14-0
DIAGNOSTIK TIDUR
284.471
293.005
298.695
304.384
273
Z-3-15-0
185.730
191.302
195.017
198.731
274
Z-3-16-0

(MRI)
596.137
614.022
625.944
637.867
275
Z-3-17-0
PENGOBATAN NUKLIR
250.271
257.780
262.785
267.790
276
Z-3-18-0
CT-SCAN KEPALA
241.132
248.366
253.188
258.011
277
Z-3-19-0
CT SCAN LAIN-LAIN
250.971
258.500
263.520
268.539
278
Z-3-20-0
170.692
175.812
179.226
182.640
279
Z-3-21-0
163.172
168.067
171.331
174.594
280
Z-3-22-0
183.962
189.481
193.160
196.839
281
Z-3-23-0
191.612
197.361
201.193
205.025
282
Z-3-24-0
376.480
387.775
395.304
402.834
283
Z-3-25-0
167.684
172.714
176.068
179.422
284
Z-3-26-0
189.516
195.201
198.992
202.782
285
Z-3-27-0
PERAWATAN LUKA
180.936
186.364
189.983
193.602
286
Z-3-28-0
IMAGING PAYUDARA
185.730
191.302
195.017
198.731
287
Z-3-29-0
IMAGING LAIN-LAIN
535.308
551.367
562.073
572.779
288
Z-3-30-0
FOTOTERAPI
90.340
93.050
94.857
96.664
- 591 5. RUMAH SAKIT PARUKELAS B NON PENDIDIKAN

a. RawatInap
No
Kode
INA-CBG
A-4-10-i
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
SEPTIKEMIA RINGAN
2.174.376
2.239.607
2.283.095
2.326.582
A-4-10-ii
SEPTIKEMIA SEDANG
2.489.076
2.563.749
2.613.530
2.663.312
A-4-10-iii
SEPTIKEMIA BERAT
3.902.402
4.019.474
4.097.522
4.175.570
A-4-11-i
3.907.861
4.025.097
4.103.254
4.181.412
A-4-11-ii
6.037.194
6.218.310
6.339.054
6.459.798
A-4-11-iii
9.875.531
10.171.797
10.369.307
10.566.818
A-4-12-i
DEMAM RINGAN
1.532.986
1.578.975
1.609.635
1.640.295
A-4-12-ii
DEMAM SEDANG
2.198.736
2.264.699
2.308.673
2.352.648
A-4-12-iii
DEMAM BERAT
2.516.293
2.591.781
2.642.107
2.692.433
10
A-4-13-i
1.916.232
1.973.719
2.012.044
2.050.369
11
A-4-13-ii
2.299.479
2.368.463
2.414.453
2.460.442
12
A-4-13-iii
2.794.745
2.878.587
2.934.482
2.990.377
1.532.986
1.578.975
1.609.635
1.640.295
2.434.702
2.507.743
2.556.437
2.605.131
2.772.448
2.855.621
2.911.070
2.966.519

LAIN-LAIN RINGAN
LAIN-LAIN SEDANG
LAIN-LAIN BERAT
13
A-4-14-i
14
A-4-14-ii
15
A-4-14-iii
16
A-4-15-i
INFEKSI HIV RINGAN
2.299.479
2.368.463
2.414.453
2.460.442
17
A-4-15-ii
INFEKSI HIV SEDANG
3.449.218
3.552.695
3.621.679
3.690.664
18
A-4-15-iii
INFEKSI HIV BERAT
4.797.050
4.940.962
5.036.903
5.132.844
19
B-1-01-i
25.493.308
26.258.107
26.767.974
27.277.840
20
B-1-01-ii
28.125.935
28.969.713
29.532.231
30.094.750
21
B-1-01-iii
49.338.677
50.818.837
51.805.611
52.792.384
22
B-1-10-i
3.305.121
3.404.275
3.470.377
3.536.479
23
B-1-10-ii
8.423.040
8.675.731
8.844.192
9.012.653
24
B-1-10-iii
14.661.180
15.101.015
15.394.239
15.687.463
2.259.482
2.327.266
2.372.456
2.417.646
5.671.513
5.841.658
5.955.088
6.068.519
7.110.670
7.323.990
7.466.203
7.608.416
4.819.556
4.964.143
5.060.534
5.156.925
10.329.488
10.639.373
10.845.963
11.052.553
12.571.377
12.948.518
13.199.945
13.451.373
25
B-1-11-i
26
B-1-11-ii
27
B-1-11-iii
28
B-1-12-i
29
B-1-12-ii
30
B-1-12-iii

(RINGAN)
(SEDANG)
(BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT
- 592 No
Kode
INA-CBG
31
B-1-13-i
32
B-1-13-ii
33
B-1-13-iii
34
B-1-14-i
35
B-1-14-ii
36
B-1-14-iii
37
B-4-10-i
38
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
3.158.148
3.252.892
3.316.055
3.379.218
5.144.165
5.298.490
5.401.373
5.504.256
7.583.942
7.811.461
7.963.140
8.114.818
4.288.543
4.417.199
4.502.970
4.588.741
4.769.725
4.912.817
5.008.211
5.103.606
7.461.668
7.685.518
7.834.751
7.983.985
1.199.364
1.235.345
1.259.332
1.283.320
B-4-10-ii
1.916.232
1.973.719
2.012.044
2.050.369
39
B-4-10-iii
2.929.692
3.017.583
3.076.176
3.134.770
40
B-4-11-i
2.896.934
2.983.842
3.041.780
3.099.719
41
B-4-11-ii
4.404.062
4.536.184
4.624.266
4.712.347
42
B-4-11-iii
4.743.328
4.885.628
4.980.495
5.075.361
43
B-4-12-i
2.541.861
2.618.117
2.668.954
2.719.791
44
B-4-12-ii
3.603.733
3.711.845
3.783.920
3.855.994
45
B-4-12-iii
7.004.179
7.214.304
7.354.388
7.494.471
46
B-4-13-i
2.299.479
2.368.463
2.414.453
2.460.442
47
B-4-13-ii
3.588.463
3.696.117
3.767.886
3.839.655
48
B-4-13-iii
5.446.525
5.609.921
5.718.852
5.827.782
49
B-4-14-i
2.299.479
2.368.463
2.414.453
2.460.442
50
B-4-14-ii
2.682.725
2.763.207
2.816.862
2.870.516
51
B-4-14-iii
3.579.026
3.686.396
3.757.977
3.829.557
52
C-4-10-i
2.239.228
2.306.405
2.351.190
2.395.974
53
C-4-10-ii
4.350.586
4.481.103
4.568.115
4.655.127
54
C-4-10-iii
LEUKEMIA AKUT BERAT
7.281.683
7.500.134
7.645.767
7.791.401
55
C-4-11-i
2.299.479
2.368.463
2.414.453
2.460.442
56
C-4-11-ii
3.065.972
3.157.951
3.219.270
3.280.590
57
C-4-11-iii
5.212.511
5.368.886
5.473.137
5.577.387
58
C-4-12-i
RADIOTERAPI RINGAN
1.532.986
1.578.975
1.609.635
1.640.295
59
C-4-12-ii
RADIOTERAPI SEDANG
4.220.773
4.347.396
4.431.812
4.516.227
60
C-4-12-iii
RADIOTERAPI BERAT
8.569.015
8.826.086
8.997.466
9.168.846
61
C-4-13-i
KEMOTERAPI RINGAN
1.532.986
1.578.975
1.609.635
1.640.295
62
C-4-13-ii
KEMOTERAPI SEDANG
3.065.972
3.157.951
3.219.270
3.280.590
63
C-4-13-iii
KEMOTERAPI BERAT
4.011.597
4.131.945
4.212.177
4.292.409

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT

PANCREAS RINGAN
PANCREAS SEDANG
PANCREAS BERAT
(RINGAN)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT
Regional 4
- 593 No
Kode
INA-CBG
64
C-4-14-i
65
C-4-14-ii
66
C-4-14-iii
67
D-1-10-i
68
D-1-10-ii
69
D-1-10-iii
70
D-1-11-i
71
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
1.987.873
2.047.509
2.087.266
2.127.024
2.904.806
2.991.951
3.050.047
3.108.143
4.428.293
4.561.142
4.649.708
4.738.274
16.312.788
16.802.172
17.128.428
17.454.683
24.845.628
25.590.997
26.087.909
26.584.822
33.672.615
34.682.793
35.356.245
36.029.698
3.352.953
3.453.542
3.520.601
3.587.660
D-1-11-ii
8.745.118
9.007.471
9.182.374
9.357.276
72
D-1-11-iii
12.390.395
12.762.107
13.009.914
13.257.722
73
D-1-20-i
4.130.132
4.254.036
4.336.638
4.419.241
74
D-1-20-ii
9.292.796
9.571.580
9.757.436
9.943.292
75
D-1-20-iii
16.798.267
17.302.215
17.638.181
17.974.146
76
D-4-10-i
1.472.527
1.516.703
1.546.153
1.575.604
77
D-4-10-ii
2.973.309
3.062.509
3.121.975
3.181.441
78
D-4-10-iii
3.832.465
3.947.439
4.024.088
4.100.737
79
D-4-11-i
3.353.407
3.454.009
3.521.077
3.588.145
80
D-4-11-ii
5.993.440
6.173.243
6.293.112
6.412.981
81
D-4-11-iii
8.205.378
8.451.540
8.615.647
8.779.755
82
D-4-12-i
1.965.689
2.024.660
2.063.973
2.103.287
83
D-4-12-ii
2.726.604
2.808.402
2.862.934
2.917.466
84
D-4-12-iii
4.186.701
4.312.302
4.396.036
4.479.770
85
D-4-13-i
1.532.986
1.578.975
1.609.635
1.640.295
86
D-4-13-ii
2.299.479
2.368.463
2.414.453
2.460.442
87
D-4-13-iii
2.682.725
2.763.207
2.816.862
2.870.516
88
D-4-14-i
1.847.061
1.902.473
1.939.414
1.976.355
89
D-4-14-ii
4.312.436
4.441.809
4.528.058
4.614.306
90
D-4-14-iii
5.144.139
5.298.463
5.401.346
5.504.229
91
E-1-01-i
3.674.729
3.784.971
3.858.466
3.931.960
92
E-1-01-ii
4.813.546
4.957.952
5.054.223
5.150.494
93
E-1-01-iii
10.910.013
11.237.313
11.455.514
11.673.714
94
E-1-10-i
3.744.352
3.856.683
3.931.570
4.006.457
95
E-1-10-ii
4.544.765
4.681.108
4.772.003
4.862.898
96
E-1-10-iii
9.579.026
9.866.397
10.057.978
10.249.558

RINGAN
SEDANG
BERAT
TULANG RINGAN
TULANG SEDANG
TULANG BERAT


RINGAN
SEDANG
BERAT
Regional 4
- 594 No
Kode
INA-CBG
97
E-1-20-i
98
E-1-20-ii
99
E-1-20-iii
100
E-4-10-i
101
E-4-10-ii
102
E-4-10-iii
103
E-4-11-i
104
E-4-11-ii
105
E-4-11-iii
106
E-4-12-i
107
E-4-12-ii
108
E-4-12-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
4.336.038
4.466.119
4.552.840
4.639.560
5.807.422
5.981.644
6.097.793
6.213.941
12.867.606
13.253.634
13.510.986
13.768.338
1.916.232
1.973.719
2.012.044
2.050.369
2.725.286
2.807.044
2.861.550
2.916.056
5.209.330
5.365.610
5.469.797
5.573.983
1.634.947
1.683.995
1.716.694
1.749.393
3.093.039
3.185.830
3.247.691
3.309.552
5.100.564
5.253.581
5.355.592
5.457.603
1.953.533
2.012.139
2.051.210
2.090.281
3.393.655
3.495.465
3.563.338
3.631.211
5.541.579
5.707.827
5.818.658
5.929.490
2.060.595
2.122.413
2.163.625
2.204.837
3.538.056
3.644.198
3.714.959
3.785.720
6.121.731
6.305.383
6.427.818
6.550.252

RINGAN
SEDANG
BERAT

RINGAN
SEDANG
BERAT
Regional 4
109
E-4-13-i
110
E-4-13-ii
111
E-4-13-iii
112
F-4-10-i
SCHIZOFRENIA RINGAN
2.519.467
2.595.051
2.645.441
2.695.830
113
F-4-10-ii
SCHIZOFRENIA SEDANG
2.797.950
2.881.888
2.937.847
2.993.806
114
F-4-10-iii
SCHIZOFRENIA BERAT
4.142.426
4.266.699
4.349.547
4.432.396
115
F-4-11-i
2.322.339
2.392.009
2.438.456
2.484.902
116
F-4-11-ii
2.705.745
2.786.917
2.841.032
2.895.147
117
F-4-11-iii
DEPRESI MAYOR BERAT
3.469.754
3.573.847
3.643.242
3.712.637
1.149.739
1.184.232
1.207.226
1.230.221
1.641.665
1.690.915
1.723.748
1.756.581
3.561.316
3.668.156
3.739.382
3.810.609

IMPULSE RINGAN
IMPULSE SEDANG
IMPULSE BERAT
118
F-4-12-i
119
F-4-12-ii
120
F-4-12-iii
121
F-4-13-i
1.876.802
1.933.107
1.970.643
2.008.179
122
F-4-13-ii
2.485.369
2.559.930
2.609.637
2.659.345
123
F-4-13-iii
3.204.566
3.300.703
3.364.794
3.428.885
124
F-4-14-i
DEPRESI RINGAN
1.313.762
1.353.175
1.379.450
1.405.725
125
F-4-14-ii
DEPRESI SEDANG
1.685.166
1.735.721
1.769.424
1.803.127
126
F-4-14-iii
DEPRESI BERAT
2.267.466
2.335.490
2.380.839
2.426.188
127
F-4-15-i
1.561.988
1.608.848
1.640.087
1.671.327
128
F-4-15-ii
2.299.479
2.368.463
2.414.453
2.460.442
129
F-4-15-iii
3.028.555
3.119.411
3.179.982
3.240.554
- 595 No
Kode
INA-CBG
130
F-4-16-i
131
F-4-16-ii
132
F-4-16-iii
133
F-4-17-i
134
F-4-17-ii
135
F-4-17-iii
136
F-4-18-i
137
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
3.364.216
3.465.143
3.532.427
3.599.712
3.910.817
4.028.142
4.106.358
4.184.575
5.220.288
5.376.897
5.481.303
5.585.708
776.758
800.060
815.596
831.131
2.276.603
2.344.901
2.390.433
2.435.965
2.428.968
2.501.837
2.550.416
2.598.996
2.915.989
3.003.469
3.061.789
3.120.109
F-4-18-ii
3.208.412
3.304.664
3.368.833
3.433.001
138
F-4-18-iii
4.946.047
5.094.428
5.193.349
5.292.270
139
F-4-19-i
2.236.289
2.303.377
2.348.103
2.392.829
140
F-4-19-ii
2.863.625
2.949.534
3.006.807
3.064.079
141
F-4-19-iii
3.565.252
3.672.209
3.743.514
3.814.819
142
G-1-01-i
7.109.639
7.322.928
7.465.121
7.607.314
143
G-1-01-ii
12.033.921
12.394.938
12.635.617
12.876.295
144
G-1-01-iii
23.296.327
23.995.216
24.461.143
24.927.069
145
G-1-10-i
3.548.069
3.654.511
3.725.472
3.796.433
146
G-1-10-ii
5.008.991
5.159.260
5.259.440
5.359.620
147
G-1-10-iii
5.936.724
6.114.826
6.233.560
6.352.294
148
G-1-11-i
4.092.803
4.215.587
4.297.443
4.379.299
149
G-1-11-ii
8.404.879
8.657.026
8.825.123
8.993.221
150
G-1-11-iii
17.599.053
18.127.024
18.479.005
18.830.986
151
G-1-12-i
3.182.995
3.278.485
3.342.145
3.405.804
152
G-1-12-ii
7.287.150
7.505.764
7.651.507
7.797.250
153
G-1-12-iii
12.852.934
13.238.522
13.495.581
13.752.639
154
G-1-13-i
839.455
864.639
881.428
898.217
155
G-1-13-ii
2.254.684
2.322.324
2.367.418
2.412.512
156
G-1-13-iii
5.087.516
5.240.142
5.341.892
5.443.642
4.010.844
4.131.169
4.211.386
4.291.603
5.418.782
5.581.345
5.689.721
5.798.097
13.267.250
13.665.268
13.930.613
14.195.958

RINGAN
SEDANG
BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

RINGAN
SEDANG
BERAT
Regional 4
157
G-1-20-i
158
G-1-20-ii
159
G-1-20-iii
160
G-1-30-i
5.115.471
5.268.935
5.371.244
5.473.554
161
G-1-30-ii
13.351.869
13.752.425
14.019.463
14.286.500
162
G-1-30-iii
17.187.982
17.703.621
18.047.381
18.391.140
- 596 No
Kode
INA-CBG
163
G-4-10-i
164
G-4-10-ii
165
G-4-10-iii
166
G-4-11-i
167
G-4-11-ii
168
G-4-11-iii
169
G-4-12-i
170
G-4-12-ii
171
G-4-12-iii
172
G-4-13-i
173
G-4-13-ii
174
G-4-13-iii
175
G-4-14-i
176
G-4-14-ii
177
G-4-14-iii
178
G-4-15-i
179
G-4-15-ii
180
G-4-15-iii
181
G-4-16-i
182
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
2.299.479
2.368.463
2.414.453
2.460.442
2.682.725
2.763.207
2.816.862
2.870.516
4.098.460
4.221.414
4.303.383
4.385.353
3.793.975
3.907.795
3.983.674
4.059.554
4.401.011
4.533.042
4.621.062
4.709.082
6.449.758
6.643.251
6.772.246
6.901.241
2.837.560
2.922.686
2.979.438
3.036.189
3.575.325
3.682.585
3.754.091
3.825.598
5.192.734
5.348.516
5.452.371
5.556.226
1.578.799
1.626.163
1.657.739
1.689.315
2.682.725
2.763.207
2.816.862
2.870.516
3.171.362
3.266.503
3.329.930
3.393.358
2.887.388
2.974.010
3.031.758
3.089.506
4.750.728
4.893.250
4.988.265
5.083.279
5.948.020
6.126.461
6.245.421
6.364.381
2.955.326
3.043.986
3.103.092
3.162.199
3.571.068
3.678.200
3.749.622
3.821.043
4.412.866
4.545.252
4.633.510
4.721.767
1.916.232
1.973.719
2.012.044
2.050.369
G-4-16-ii
2.865.743
2.951.715
3.009.030
3.066.345
183
G-4-16-iii
5.200.811
5.356.836
5.460.852
5.564.868
184
G-4-17-i
2.738.471
2.820.625
2.875.395
2.930.164
185
G-4-17-ii
3.398.563
3.500.520
3.568.492
3.636.463
186
G-4-17-iii
5.696.020
5.866.901
5.980.821
6.094.742
187
G-4-18-i
2.299.479
2.368.463
2.414.453
2.460.442
188
G-4-18-ii
3.297.055
3.395.966
3.461.907
3.527.848
189
G-4-18-iii
3.492.894
3.597.681
3.667.538
3.737.396
190
G-4-19-i
1.916.232
1.973.719
2.012.044
2.050.369
191
G-4-19-ii
3.883.503
4.000.008
4.077.678
4.155.348
192
G-4-19-iii
5.792.953
5.966.742
6.082.601
6.198.460

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
DEGENERATIF RINGAN
DEGENERATIF SEDANG
DEGENERATIF BERAT
RINGAN
SEDANG
BERAT
TRAUMATIK RINGAN
TRAUMATIK SEDANG
TRAUMATIK BERAT
DENGAN INFARK BERAT
TANPA INFARK RINGAN
TANPA INFARK SEDANG
TANPA INFARK BERAT

PERIFER RINGAN
PERIFER SEDANG
PERIFER BERAT
PERSARAFAN RINGAN
PERSARAFAN SEDANG
PERSARAFAN BERAT
SEDANG
Regional 4
- 597 No
Kode
INA-CBG
193
G-4-20-i
194
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
1.341.363
1.381.604
1.408.431
1.435.258
G-4-20-ii
1.904.736
1.961.879
1.999.973
2.038.068
195
G-4-20-iii
3.248.022
3.345.463
3.410.423
3.475.383
196
G-4-21-i
1.554.333
1.600.963
1.632.049
1.663.136
197
G-4-21-ii
3.219.178
3.315.754
3.380.137
3.444.521
198
G-4-21-iii
3.792.572
3.906.349
3.982.200
4.058.052
199
G-4-22-i
1.532.986
1.578.975
1.609.635
1.640.295
200
G-4-22-ii
1.916.232
1.973.719
2.012.044
2.050.369
201
G-4-22-iii
2.198.419
2.264.372
2.308.340
2.352.309
202
G-4-23-i
1.532.986
1.578.975
1.609.635
1.640.295
203
G-4-23-ii
1.916.232
1.973.719
2.012.044
2.050.369
204
G-4-23-iii
2.739.118
2.821.292
2.876.074
2.930.857
205
G-4-24-i
1.532.986
1.578.975
1.609.635
1.640.295
206
G-4-24-ii
1.916.232
1.973.719
2.012.044
2.050.369
207
G-4-24-iii
TRAUMA KEPALA BERAT
4.026.755
4.147.558
4.228.093
4.308.628
208
G-4-25-i
GEGAR OTAK RINGAN
1.456.636
1.500.335
1.529.468
1.558.600
209
G-4-25-ii
GEGAR OTAK SEDANG
1.833.937
1.888.955
1.925.634
1.962.312
210
G-4-25-iii
GEGAR OTAK BERAT
2.392.780
2.464.564
2.512.419
2.560.275
211
G-4-26-i
2.299.479
2.368.463
2.414.453
2.460.442
212
G-4-26-ii
2.682.725
2.763.207
2.816.862
2.870.516
213
G-4-26-iii
5.120.947
5.274.576
5.376.995
5.479.414
214
H-1-20-i
2.203.501
2.269.606
2.313.676
2.357.746
215
H-1-20-ii
4.018.334
4.138.884
4.219.250
4.299.617
216
H-1-20-iii
5.464.683
5.628.623
5.737.917
5.847.211
217
H-1-30-i
2.157.437
2.222.161
2.265.309
2.308.458
218
H-1-30-ii
2.459.479
2.533.263
2.582.453
2.631.642
219
H-1-30-iii
4.103.551
4.226.658
4.308.729
4.390.800
220
H-4-10-i
2.299.479
2.368.463
2.414.453
2.460.442
221
H-4-10-ii
3.832.465
3.947.439
4.024.088
4.100.737
222
H-4-10-iii
6.248.049
6.435.491
6.560.452
6.685.413
223
H-4-11-i
1.565.692
1.612.663
1.643.977
1.675.291
224
H-4-11-ii
1.749.428
1.801.911
1.836.900
1.871.888
225
H-4-11-iii
2.501.519
2.576.564
2.626.595
2.676.625
226
H-4-12-i
2.172.336
2.237.506
2.280.952
2.324.399

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)

RINGAN
SEDANG
Regional 4
- 598 No
Kode
INA-CBG
227
H-4-12-ii
228
H-4-12-iii
229
I-1-01-i
230
I-1-01-ii
231
I-1-01-iii
232
I-1-02-i
233
I-1-02-ii
234
I-1-02-iii
235
I-1-03-i
236
I-1-03-ii
237
I-1-03-iii
238
I-1-04-i
239
I-1-04-ii
240
I-1-04-iii
241
I-1-05-i
242
I-1-05-ii
243
I-1-05-iii
244
I-1-06-i
245
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
2.942.571
3.030.848
3.089.699
3.148.551
4.909.479
5.056.763
5.154.953
5.253.142
33.072.334
34.064.505
34.725.951
35.387.398
33.800.098
34.814.101
35.490.103
36.166.105
53.352.807
54.953.391
56.020.447
57.087.503
18.348.341
18.898.791
19.265.758
19.632.725
23.669.359
24.379.440
24.852.827
25.326.215
29.173.862
30.049.078
30.632.555
31.216.032
11.299.561
11.638.548
11.864.539
12.090.530
15.487.993
15.952.633
16.262.393
16.572.153
22.715.724
23.397.195
23.851.510
24.305.824
13.785.133
14.198.687
14.474.390
14.750.093
17.707.248
18.238.466
18.592.611
18.946.756
37.748.177
38.880.622
39.635.586
40.390.550
24.284.569
25.013.106
25.498.797
25.984.488
29.141.482
30.015.727
30.598.556
31.181.386
40.098.496
41.301.451
42.103.420
42.905.390
11.447.207
11.790.623
12.019.567
12.248.511
I-1-06-ii
17.276.553
17.794.849
18.140.380
18.485.911
246
I-1-06-iii
22.241.100
22.908.333
23.353.155
23.797.977
247
I-1-07-i
15.053.944
15.505.562
15.806.641
16.107.720
248
I-1-07-ii
18.572.098
19.129.261
19.500.703
19.872.145
249
I-1-07-iii
20.262.038
20.869.899
21.275.140
21.680.381
250
I-1-11-i
2.863.627
2.949.536
3.006.809
3.064.081
251
I-1-11-ii
3.184.067
3.279.589
3.343.270
3.406.952
252
I-1-11-iii
4.237.023
4.364.134
4.448.874
4.533.614
253
I-1-12-i
8.776.530
9.039.825
9.215.356
9.390.887
254
I-1-12-ii
12.177.845
12.543.180
12.786.737
13.030.294
255
I-1-12-iii
16.985.218
17.494.775
17.834.479
18.174.184

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
KATETERISASI RINGAN
KATETERISASI SEDANG
KATETERISASI BERAT
RINGAN
SEDANG
BERAT

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
Regional 4
- 599 No
Kode
INA-CBG
256
I-1-13-i
257
I-1-13-ii
258
I-1-13-iii
259
I-1-14-i
260
I-1-14-ii
261
I-1-14-iii
262
I-1-15-i
263
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
5.162.664
5.317.544
5.420.798
5.524.051
6.006.444
6.186.637
6.306.766
6.426.895
10.949.345
11.277.826
11.496.813
11.715.799
18.887.998
19.454.638
19.832.398
20.210.158
23.475.083
24.179.335
24.648.837
25.118.339
30.760.453
31.683.267
32.298.476
32.913.685
3.701.142
3.812.176
3.886.199
3.960.222
I-1-15-ii
10.841.595
11.166.843
11.383.675
11.600.507
264
I-1-15-iii
56.117.717
57.801.248
58.923.602
60.045.957
265
I-1-16-i
8.094.856
8.337.702
8.499.599
8.661.496
266
I-1-16-ii
21.046.626
21.678.025
22.098.957
22.519.890
267
I-1-16-iii
24.276.767
25.005.070
25.490.605
25.976.140
268
I-1-17-i
2.596.085
2.673.968
2.725.890
2.777.811
269
I-1-17-ii
5.377.434
5.538.757
5.646.306
5.753.855
270
I-1-17-iii
31.175.092
32.110.345
32.733.847
33.357.349
271
I-1-20-i
3.097.599
3.190.527
3.252.478
3.314.430
272
I-1-20-ii
5.575.677
5.742.948
5.854.461
5.965.975
273
I-1-20-iii
7.434.237
7.657.264
7.805.949
7.954.633
274
I-1-30-i
9.183.656
9.459.166
9.642.839
9.826.512
275
I-1-30-ii
19.103.861
19.676.976
20.059.054
20.441.131
276
I-1-30-iii
29.604.045
30.492.167
31.084.248
31.676.329
277
I-1-40-i
12.349.948
12.720.446
12.967.445
13.214.444
278
I-1-40-ii
17.151.424
17.665.967
18.008.996
18.352.024
279
I-1-40-iii
21.491.521
22.136.267
22.566.097
22.995.927
280
I-4-10-i
3.591.724
3.699.475
3.771.310
3.843.144
281
I-4-10-ii
5.671.396
5.841.538
5.954.966
6.068.394
282
I-4-10-iii
8.181.483
8.426.928
8.590.558
8.754.187
283
I-4-11-i
4.258.845
4.386.610
4.471.787
4.556.964
284
I-4-11-ii
5.270.337
5.428.447
5.533.854
5.639.261

KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

DARAH VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
Regional 4
- 600 No
Kode
INA-CBG
285
I-4-11-iii
286
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
9.327.246
9.607.063
9.793.608
9.980.153
I-4-12-i
3.730.305
3.842.215
3.916.821
3.991.427
287
I-4-12-ii
5.323.135
5.482.829
5.589.292
5.695.755
288
I-4-12-iii
6.457.712
6.651.443
6.780.598
6.909.752
3.350.840
3.451.365
3.518.382
3.585.399
4.868.086
5.014.129
5.111.491
5.208.852
9.964.408
10.263.341
10.462.629
10.661.917

VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
Regional 4
289
I-4-13-i
290
I-4-13-ii
291
I-4-13-iii
292
I-4-14-i
2.083.913
2.146.430
2.188.108
2.229.787
293
I-4-14-ii
2.438.486
2.511.641
2.560.410
2.609.180
294
I-4-14-iii
3.778.842
3.892.208
3.967.784
4.043.361
3.065.972
3.157.951
3.219.270
3.280.590
4.389.090
4.520.763
4.608.545
4.696.327
5.002.507
5.152.582
5.252.633
5.352.683

295
I-4-15-i
296
I-4-15-ii
297
I-4-15-iii
298
I-4-16-i
2.299.479
2.368.463
2.414.453
2.460.442
299
I-4-16-ii
3.726.663
3.838.463
3.912.996
3.987.530
300
I-4-16-iii
4.694.934
4.835.782
4.929.681
5.023.579
301
I-4-17-i
HIPERTENSI RINGAN
2.057.986
2.119.726
2.160.885
2.202.045
302
I-4-17-ii
HIPERTENSI SEDANG
2.914.313
3.001.742
3.060.029
3.118.315
303
I-4-17-iii
HIPERTENSI BERAT
3.545.401
3.651.763
3.722.671
3.793.579
3.030.822
3.121.747
3.182.363
3.242.980
4.643.017
4.782.307
4.875.168
4.968.028
6.259.531
6.447.317
6.572.507
6.697.698
2.372.016
2.443.176
2.490.616
2.538.057
3.885.287
4.001.846
4.079.552
4.157.257
4.631.227
4.770.164
4.862.788
4.955.413

RINGAN
SEDANG
KONGENITAL BERAT
RINGAN
SEDANG
BERAT
304
I-4-18-i
305
I-4-18-ii
306
I-4-18-iii
307
I-4-19-i
308
I-4-19-ii
309
I-4-19-iii
310
I-4-20-i
2.878.777
2.965.140
3.022.716
3.080.291
311
I-4-20-ii
3.316.566
3.416.063
3.482.394
3.548.726
312
I-4-20-iii
4.401.635
4.533.684
4.621.717
4.709.750
313
I-4-21-i
3.828.307
3.943.157
4.019.723
4.096.289
314
I-4-21-ii
4.775.565
4.918.832
5.014.343
5.109.855
315
I-4-21-iii
6.514.883
6.710.330
6.840.628
6.970.925
316
I-4-22-i
2.491.102
2.565.835
2.615.657
2.665.479
317
I-4-22-ii
2.870.495
2.956.610
3.014.020
3.071.430
- 601 No
Kode
INA-CBG
318
I-4-22-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.187.975
4.313.614
4.397.373
4.481.133
1.887.150
1.943.765
1.981.508
2.019.251
2.316.986
2.386.495
2.432.835
2.479.175
4.527.179
4.662.994
4.753.538
4.844.081
2.250.825
2.318.350
2.363.367
2.408.383
5.619.688
5.788.279
5.900.673
6.013.067
7.105.081
7.318.233
7.460.335
7.602.436
23.266.717
23.964.719
24.430.053
24.895.388
25.342.657
26.102.936
26.609.789
27.116.642
37.578.445
38.705.798
39.457.367
40.208.936
10.524.575
10.840.312
11.050.804
11.261.295
11.274.624
11.612.863
11.838.355
12.063.848
16.660.682
17.160.502
17.493.716
17.826.929
4.106.841
4.230.047
4.312.183
4.394.320
9.919.514
10.217.100
10.415.490
10.613.880
17.563.719
18.090.631
18.441.905
18.793.179
3.549.625
3.656.114
3.727.106
3.798.099
5.162.649
5.317.529
5.420.782
5.524.035
7.763.030
7.995.921
8.151.181
8.306.442
2.393.708
2.465.519
2.513.394
2.561.268
12.996.234
13.386.121
13.646.046
13.905.971
39.196.071
40.371.954
41.155.875
41.939.796
319
I-4-23-i
320
I-4-23-ii
321
I-4-23-iii
322
I-4-24-i
323
I-4-24-ii
324
I-4-24-iii
325
J-1-01-i
326
J-1-01-ii
327
J-1-01-iii
328
J-1-02-i
329
J-1-02-ii
330
J-1-02-iii
331
J-1-10-i
332
J-1-10-ii
333
J-1-10-iii
334
J-1-20-i
335
J-1-20-ii
336
J-1-20-iii
337
J-1-30-i
338
J-1-30-ii
339
J-1-30-iii
340
J-4-10-i
3.062.731
3.154.613
3.215.868
3.277.123
341
J-4-10-ii
4.379.338
4.510.718
4.598.305
4.685.892
342
J-4-10-iii
6.625.285
6.824.043
6.956.549
7.089.055
343
J-4-11-i
1.742.886
1.795.173
1.830.031
1.864.888
344
J-4-11-ii
2.426.058
2.498.840
2.547.361
2.595.882
345
J-4-11-iii
3.476.603
3.580.901
3.650.433
3.719.965
346
J-4-12-i
EMBOLI PARU RINGAN
2.954.826
3.043.471
3.102.568
3.161.664
347
J-4-12-ii
EMBOLI PARU SEDANG
3.826.399
3.941.191
4.017.719
4.094.247
348
J-4-12-iii
EMBOLI PARU BERAT
5.109.769
5.263.062
5.365.258
5.467.453
- 602 No
Kode
INA-CBG
349
J-4-13-i
350
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
4.105.614
4.228.782
4.310.894
4.393.007
J-4-13-ii
6.035.252
6.216.310
6.337.015
6.457.720
351
J-4-13-iii
9.812.417
10.106.789
10.303.037
10.499.286
352
J-4-14-i
TUMOR PARU RINGAN
2.894.297
2.981.126
3.039.012
3.096.897
353
J-4-14-ii
TUMOR PARU SEDANG
4.686.775
4.827.378
4.921.114
5.014.849
354
J-4-14-iii
TUMOR PARU BERAT
5.572.337
5.739.507
5.850.954
5.962.401
2.894.297
2.981.126
3.039.012
3.096.897
3.448.912
3.552.379
3.621.357
3.690.335
4.683.369
4.823.871
4.917.538
5.011.205
2.411.914
2.484.271
2.532.510
2.580.748
3.376.680
3.477.980
3.545.513
3.613.047
6.091.175
6.273.910
6.395.733
6.517.557

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
Regional 4
355
J-4-15-i
356
J-4-15-ii
357
J-4-15-iii
358
J-4-16-i
359
J-4-16-ii
360
J-4-16-iii
361
J-4-17-i
2.411.914
2.484.271
2.532.510
2.580.748
362
J-4-17-ii
2.894.297
2.981.126
3.039.012
3.096.897
363
J-4-17-iii
5.320.998
5.480.628
5.587.048
5.693.468
364
J-4-18-i
1.929.531
1.987.417
2.026.008
2.064.598
365
J-4-18-ii
2.653.105
2.732.698
2.785.761
2.838.823
366
J-4-18-iii
2.793.557
2.877.364
2.933.235
2.989.106
367
J-4-19-i
3.376.680
3.477.980
3.545.513
3.613.047
368
J-4-19-ii
3.859.062
3.974.834
4.052.015
4.129.197
369
J-4-19-iii
6.045.674
6.227.044
6.347.957
6.468.871
370
J-4-20-i
3.376.680
3.477.980
3.545.513
3.613.047
371
J-4-20-ii
3.859.062
3.974.834
4.052.015
4.129.197
372
J-4-20-iii
9.307.285
9.586.504
9.772.650
9.958.795
1.929.531
1.987.417
2.026.008
2.064.598
4.760.506
4.903.321
4.998.531
5.093.741
6.790.038
6.993.739
7.129.540
7.265.341
4.130.132
4.254.036
4.336.638
4.419.241
5.763.870
5.936.786
6.052.063
6.167.341
6.750.484
6.952.999
7.088.008
7.223.018

USUS BESAR (RINGAN)
USUS BESAR (SEDANG)
USUS BESAR (BERAT)
373
J-4-21-i
374
J-4-21-ii
375
J-4-21-iii
376
K-1-10-i
377
K-1-10-ii
378
K-1-10-iii
379
K-1-11-i
3.551.278
3.657.816
3.728.842
3.799.867
380
K-1-11-ii
4.662.399
4.802.271
4.895.519
4.988.767
381
K-1-11-iii
11.832.252
12.187.219
12.423.864
12.660.509
- 603 No
Kode
INA-CBG
382
K-1-12-i
383
K-1-12-ii
384
K-1-12-iii
385
K-1-13-i
386
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
1.910.316
1.967.625
2.005.831
2.044.038
2.489.732
2.564.424
2.614.219
2.664.014
4.952.601
5.101.179
5.200.231
5.299.283
2.169.857
2.234.953
2.278.350
2.321.747
K-1-13-ii
3.790.117
3.903.820
3.979.622
4.055.425
387
K-1-13-iii
4.053.393
4.174.995
4.256.063
4.337.130
388
K-1-14-i
3.506.617
3.611.816
3.681.948
3.752.080
389
K-1-14-ii
4.118.919
4.242.487
4.324.865
4.407.243
390
K-1-14-iii
10.141.973
10.446.232
10.649.071
10.851.911
391
K-1-20-i
6.803.866
7.007.982
7.144.059
7.280.136
392
K-1-20-ii
9.496.402
9.781.294
9.971.222
10.161.150
393
K-1-20-iii
20.284.764
20.893.307
21.299.002
21.704.697
394
K-1-30-i
4.478.643
4.613.002
4.702.575
4.792.148
395
K-1-30-ii
8.260.263
8.508.071
8.673.276
8.838.482
396
K-1-30-iii
12.864.300
13.250.229
13.507.515
13.764.801
397
K-1-40-i
4.499.338
4.634.318
4.724.304
4.814.291
398
K-1-40-ii
4.951.074
5.099.606
5.198.628
5.297.649
399
K-1-40-iii
8.210.880
8.457.206
8.621.424
8.785.641
400
K-1-50-i
3.431.909
3.534.866
3.603.504
3.672.143
401
K-1-50-ii
4.444.484
4.577.819
4.666.708
4.755.598
402
K-1-50-iii
PROSEDUR ANAL BERAT
6.309.985
6.499.285
6.625.485
6.751.684
403
K-4-10-i
2.599.424
2.677.407
2.729.395
2.781.384
404
K-4-10-ii
3.110.364
3.203.675
3.265.882
3.328.089
405
K-4-10-iii
12.879.976
13.266.375
13.523.975
13.781.574
406
K-4-11-i
1.532.986
1.578.975
1.609.635
1.640.295
407
K-4-11-ii
2.299.479
2.368.463
2.414.453
2.460.442
408
K-4-11-iii
4.178.982
4.304.351
4.387.931
4.471.510
409
K-4-12-i
1.532.986
1.578.975
1.609.635
1.640.295
410
K-4-12-ii
2.290.257
2.358.965
2.404.770
2.450.575
411
K-4-12-iii
5.496.454
5.661.348
5.771.277
5.881.206
412
K-4-13-i
2.299.479
2.368.463
2.414.453
2.460.442
413
K-4-13-ii
2.978.391
3.067.743
3.127.311
3.186.879


RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)

(RINGAN)
(SEDANG)
Regional 4
- 604 No
Kode
INA-CBG
414
K-4-13-iii
415
K-4-14-i
416
K-4-14-ii
417
K-4-14-iii
418
K-4-15-i
419
K-4-15-ii
420
K-4-15-iii
421
K-4-16-i
422
K-4-16-ii
423
K-4-16-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
4.871.345
5.017.485
5.114.912
5.212.339
1.916.232
1.973.719
2.012.044
2.050.369
2.593.421
2.671.223
2.723.092
2.774.960
3.922.796
4.040.480
4.118.936
4.197.392
1.916.232
1.973.719
2.012.044
2.050.369
3.603.040
3.711.131
3.783.192
3.855.252
5.126.477
5.280.271
5.382.801
5.485.330
1.916.232
1.973.719
2.012.044
2.050.369
2.299.479
2.368.463
2.414.453
2.460.442
2.806.813
2.891.017
2.947.153
3.003.290
1.532.986
1.578.975
1.609.635
1.640.295
2.236.655
2.303.755
2.348.488
2.393.221
2.976.760
3.066.062
3.125.598
3.185.133
1.532.986
1.578.975
1.609.635
1.640.295
2.379.830
2.451.225
2.498.822
2.546.418
2.815.327
2.899.787
2.956.093
3.012.400
15.687.430
16.158.053
16.471.802
16.785.550
16.319.252
16.808.829
17.135.214
17.461.600
25.002.978
25.753.067
26.253.127
26.753.186
7.115.357
7.328.817
7.471.124
7.613.431
10.306.617
10.615.815
10.821.948
11.028.080
10.870.265
11.196.373
11.413.778
11.631.183
2.872.974
2.959.163
3.016.623
3.074.082
6.466.202
6.660.188
6.789.512
6.918.836
10.958.504
11.287.259
11.506.429
11.725.599

RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
Regional 4
424
K-4-17-i
425
K-4-17-ii
426
K-4-17-iii
427
K-4-18-i
428
K-4-18-ii
429
K-4-18-iii
430
L-1-20-i
431
L-1-20-ii
432
L-1-20-iii
433
L-1-30-i
434
L-1-30-ii
435
L-1-30-iii
436
L-1-40-i
437
L-1-40-ii
438
L-1-40-iii
439
L-1-50-i
5.162.664
5.317.544
5.420.798
5.524.051
440
L-1-50-ii
9.292.796
9.571.580
9.757.436
9.943.292
441
L-1-50-iii
11.236.305
11.573.394
11.798.120
12.022.847
442
L-4-10-i
2.299.479
2.368.463
2.414.453
2.460.442
443
L-4-10-ii
2.682.725
2.763.207
2.816.862
2.870.516
444
L-4-10-iii
5.426.924
5.589.732
5.698.270
5.806.809
445
L-4-11-i
2.174.888
2.240.135
2.283.633
2.327.130
- 605 No
Kode
INA-CBG
446
L-4-11-ii
447
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
2.979.559
3.068.946
3.128.537
3.188.128
L-4-11-iii
8.080.191
8.322.597
8.484.200
8.645.804
448
L-4-12-i
2.299.479
2.368.463
2.414.453
2.460.442
449
L-4-12-ii
3.373.869
3.475.085
3.542.562
3.610.040
450
L-4-12-iii
5.657.579
5.827.306
5.940.458
6.053.610
451
L-4-13-i
1.443.313
1.486.613
1.515.479
1.544.345
452
L-4-13-ii
1.664.226
1.714.152
1.747.437
1.780.721
453
L-4-13-iii
2.496.468
2.571.362
2.621.292
2.671.221
454
L-4-14-i
1.532.986
1.578.975
1.609.635
1.640.295
455
L-4-14-ii
2.299.479
2.368.463
2.414.453
2.460.442
456
L-4-14-iii
3.595.277
3.703.135
3.775.040
3.846.946
457
M-1-01-i
7.473.904
7.698.121
7.847.599
7.997.077
458
M-1-01-ii
8.342.085
8.592.348
8.759.190
8.926.031
459
M-1-01-iii
11.718.370
12.069.921
12.304.288
12.538.656
460
M-1-02-i
5.293.430
5.452.233
5.558.101
5.663.970
461
M-1-02-ii
8.690.806
8.951.530
9.125.346
9.299.162
462
M-1-02-iii
15.738.650
16.210.810
16.525.583
16.840.356
13.422.928
13.825.615
14.094.074
14.362.533
15.708.751
16.180.013
16.494.188
16.808.363
16.004.260
16.484.388
16.804.473
17.124.558
3.491.917
3.596.675
3.666.513
3.736.351
4.476.601
4.610.899
4.700.432
4.789.964
5.601.623
5.769.672
5.881.704
5.993.736
5.439.736
5.602.928
5.711.723
5.820.518
6.286.877
6.475.484
6.601.221
6.726.959
10.708.264
11.029.512
11.243.678
11.457.843
6.004.707
6.184.849
6.304.943
6.425.037
8.044.431
8.285.764
8.446.653
8.607.542
16.387.270
16.878.888
17.206.633
17.534.378
3.752.827
3.865.411
3.940.468
4.015.525
13.940.051
14.358.252
14.637.053
14.915.854
17.051.339
17.562.879
17.903.906
18.244.933
463
M-1-03-i
464
M-1-03-ii
465
M-1-03-iii
466
M-1-04-i
467
M-1-04-ii
468
M-1-04-iii
469
M-1-05-i
470
M-1-05-ii
471
M-1-05-iii
472
M-1-07-i
473
M-1-07-ii
474
M-1-07-iii
475
M-1-10-i
476
M-1-10-ii
477
M-1-10-iii


TULANG WAJAH RINGAN
TULANG WAJAH SEDANG
TULANG WAJAH BERAT
Regional 4
- 606 No
Kode
INA-CBG
478
M-1-20-i
479
M-1-20-ii
480
M-1-20-iii
481
M-1-30-i
482
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
3.712.515
3.823.891
3.898.141
3.972.391
5.299.282
5.458.261
5.564.246
5.670.232
10.300.649
10.609.669
10.815.682
11.021.695
2.220.639
2.287.258
2.331.671
2.376.084
M-1-30-ii
4.588.405
4.726.057
4.817.825
4.909.594
483
M-1-30-iii
PROSEDUR KAKI BERAT
6.844.933
7.050.281
7.187.180
7.324.078
484
M-1-40-i
2.243.783
2.311.097
2.355.972
2.400.848
485
M-1-40-ii
4.130.132
4.254.036
4.336.638
4.419.241
486
M-1-40-iii
7.227.730
7.444.562
7.589.117
7.733.671
487
M-1-50-i
2.971.608
3.060.756
3.120.189
3.179.621
488
M-1-50-ii
5.981.917
6.161.375
6.281.013
6.400.651
489
M-1-50-iii
8.260.263
8.508.071
8.673.276
8.838.482
2.242.626
2.309.905
2.354.758
2.399.610
4.489.753
4.624.445
4.714.240
4.804.036
7.813.758
8.048.171
8.204.446
8.360.721
3.004.218
3.094.344
3.154.429
3.214.513
6.130.092
6.313.995
6.436.597
6.559.199
9.882.449
10.178.922
10.376.571
10.574.220

SENDI MAYOR RINGAN
SENDI MAYOR SEDANG
SENDI MAYOR BERAT

RINGAN
SEDANG
BERAT

SELAIN KAKI (BERAT)
Regional 4
490
M-1-60-i
491
M-1-60-ii
492
M-1-60-iii
493
M-1-70-i
494
M-1-70-ii
495
M-1-70-iii
496
M-1-80-i
2.420.586
2.493.204
2.541.616
2.590.028
497
M-1-80-ii
3.659.432
3.769.215
3.842.403
3.915.592
498
M-1-80-iii
8.424.960
8.677.709
8.846.208
9.014.707
499
M-4-10-i
1.532.986
1.578.975
1.609.635
1.640.295
500
M-4-10-ii
2.338.952
2.409.120
2.455.899
2.502.678
501
M-4-10-iii
FRAKTUR FEMUR BERAT
4.966.640
5.115.639
5.214.972
5.314.305
502
M-4-11-i
2.028.829
2.089.694
2.130.270
2.170.847
503
M-4-11-ii
4.654.436
4.794.069
4.887.157
4.980.246
504
M-4-11-iii
8.261.514
8.509.360
8.674.590
8.839.820
505
M-4-12-i
1.532.986
1.578.975
1.609.635
1.640.295
506
M-4-12-ii
2.789.266
2.872.944
2.928.729
2.984.515
507
M-4-12-iii
5.586.170
5.753.755
5.865.479
5.977.202
508
M-4-13-i
2.830.027
2.914.928
2.971.529
3.028.129

PANGGUL RINGAN
PANGGUL SEDANG
PANGGUL BERAT
PELVIS RINGAN
PELVIS SEDANG
PELVIS BERAT
- 607 No
Kode
INA-CBG
509
M-4-13-ii
510
M-4-13-iii
511
M-4-14-i
512
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
3.832.465
3.947.439
4.024.088
4.100.737
8.418.622
8.671.181
8.839.554
9.007.926
3.065.972
3.157.951
3.219.270
3.280.590
M-4-14-ii
3.980.453
4.099.867
4.179.476
4.259.085
513
M-4-14-iii
OSTEOMIELITIS BERAT
5.962.290
6.141.159
6.260.405
6.379.651
514
M-4-15-i
1.912.838
1.970.224
2.008.480
2.046.737
515
M-4-15-ii
2.550.612
2.627.131
2.678.143
2.729.155
516
M-4-15-iii
6.515.190
6.710.646
6.840.950
6.971.253
517
M-4-16-i
1.916.232
1.973.719
2.012.044
2.050.369
518
M-4-16-ii
3.065.972
3.157.951
3.219.270
3.280.590
519
M-4-16-iii
5.700.955
5.871.984
5.986.003
6.100.022
1.916.232
1.973.719
2.012.044
2.050.369
2.682.725
2.763.207
2.816.862
2.870.516
3.746.568
3.858.965
3.933.897
4.008.828
2.246.122
2.313.506
2.358.428
2.403.350
3.065.972
3.157.951
3.219.270
3.280.590
3.809.292
3.923.570
3.999.756
4.075.942
1.670.022
1.720.123
1.753.523
1.786.924
2.812.852
2.897.238
2.953.495
3.009.752
5.493.708
5.658.519
5.768.394
5.878.268
1.532.986
1.578.975
1.609.635
1.640.295
2.299.479
2.368.463
2.414.453
2.460.442
2.548.365
2.624.815
2.675.783
2.726.750
1.532.986
1.578.975
1.609.635
1.640.295
2.000.932
2.060.960
2.100.979
2.140.997
4.877.428
5.023.751
5.121.299
5.218.848

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
RINGAN
SEDANG
BERAT
ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
Regional 4
520
M-4-17-i
521
M-4-17-ii
522
M-4-17-iii
523
M-4-18-i
524
M-4-18-ii
525
M-4-18-iii
526
M-4-19-i
527
M-4-19-ii
528
M-4-19-iii
529
M-4-20-i
530
M-4-20-ii
531
M-4-20-iii
532
M-4-21-i
533
M-4-21-ii
534
M-4-21-iii
535
N-1-01-i
4.147.845
4.272.281
4.355.237
4.438.194
536
N-1-01-ii
5.609.867
5.778.163
5.890.360
6.002.558
537
N-1-01-iii
11.894.587
12.251.424
12.489.316
12.727.208
5.722.273
5.893.941
6.008.386
6.122.832
7.739.245
7.971.422
8.126.207
8.280.992
538
N-1-11-i
539
N-1-11-ii

RINGAN
SEDANG
- 608 No
Kode
INA-CBG
540
N-1-11-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
16.409.501
16.901.786
17.229.976
17.558.166
3.097.599
3.190.527
3.252.479
3.314.431
7.206.344
7.422.534
7.566.661
7.710.788
13.134.011
13.528.031
13.790.712
14.053.392
541
N-1-12-i
542
N-1-12-ii
543
N-1-12-iii
544
N-1-20-i
4.193.904
4.319.721
4.403.599
4.487.477
545
N-1-20-ii
8.315.021
8.564.471
8.730.772
8.897.072
546
N-1-20-iii
9.511.630
9.796.979
9.987.211
10.177.444
4.989.389
5.139.071
5.238.858
5.338.646
7.581.999
7.809.459
7.961.099
8.112.739
8.728.131
8.989.975
9.164.538
9.339.100
4.495.928
4.630.806
4.720.724
4.810.643
6.094.391
6.277.222
6.399.110
6.520.998
7.087.952
7.300.591
7.442.350
7.584.109
1.916.232
1.973.719
2.012.044
2.050.369
2.565.889
2.642.865
2.694.183
2.745.501
5.616.269
5.784.757
5.897.082
6.009.407

URIN BAWAH RINGAN
URIN BAWAH SEDANG
URIN BAWAH BERAT
RINGAN
SEDANG
BERAT
GINJAL RINGAN
GINJAL SEDANG
GINJAL BERAT
547
N-1-30-i
548
N-1-30-ii
549
N-1-30-iii
550
N-1-40-i
551
N-1-40-ii
552
N-1-40-iii
553
N-4-10-i
554
N-4-10-ii
555
N-4-10-iii
556
N-4-11-i
1.467.457
1.511.480
1.540.830
1.570.179
557
N-4-11-ii
2.479.967
2.554.366
2.603.965
2.653.564
558
N-4-11-iii
2.874.349
2.960.579
3.018.066
3.075.553
559
N-4-12-i
1.532.986
1.578.975
1.609.635
1.640.295
560
N-4-12-ii
2.299.479
2.368.463
2.414.453
2.460.442
561
N-4-12-iii
3.817.891
3.932.427
4.008.785
4.085.143
562
N-4-13-i
BATU URIN RINGAN
2.022.480
2.083.154
2.123.604
2.164.053
563
N-4-13-ii
BATU URIN SEDANG
2.438.350
2.511.500
2.560.267
2.609.034
564
N-4-13-iii
BATU URIN BERAT
6.004.987
6.185.137
6.305.236
6.425.336
1.327.850
1.367.685
1.394.242
1.420.799
2.044.722
2.106.064
2.146.958
2.187.852
3.315.887
3.415.364
3.481.681
3.547.999
1.969.969
2.029.068
2.068.467
2.107.867
565
N-4-14-i
566
N-4-14-ii
567
N-4-14-iii
568
N-4-15-i

(RINGAN)
(SEDANG)
(BERAT)
SALURAN URIN RINGAN
- 609 No
Kode
INA-CBG
569
N-4-15-ii
570
N-4-15-iii
571
N-4-16-i
572
N-4-16-ii
573
N-4-16-iii
574
O-6-10-i
575
O-6-10-ii
576
O-6-10-iii
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
584
O-6-13-ii
585
O-6-13-iii
586
P-8-01-i
587
P-8-01-ii
588
P-8-01-iii
589
P-8-02-i
590
P-8-02-ii
591
P-8-02-iii
592
P-8-03-i
593
P-8-03-ii
594
P-8-03-iii
595
P-8-04-i
596
P-8-04-ii
597
P-8-04-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
2.703.410
2.784.513
2.838.581
2.892.649
3.085.079
3.177.631
3.239.333
3.301.035
2.556.747
2.633.450
2.684.585
2.735.720
3.065.972
3.157.951
3.219.270
3.280.590
6.447.283
6.640.701
6.769.647
6.898.592
3.775.164
3.888.419
3.963.922
4.039.425
4.191.007
4.316.737
4.400.558
4.484.378
4.698.169
4.839.114
4.933.078
5.027.041
1.973.036
2.032.227
2.071.687
2.111.148
2.531.225
2.607.161
2.657.786
2.708.410
4.289.640
4.418.329
4.504.122
4.589.915
1.718.129
1.769.672
1.804.035
1.838.398
2.063.468
2.125.372
2.166.642
2.207.911
2.592.452
2.670.226
2.722.075
2.773.924
1.721.875
1.773.531
1.807.968
1.842.406
2.537.705
2.613.836
2.664.590
2.715.345
2.999.176
3.089.151
3.149.135
3.209.118
38.517.557
39.673.083
40.443.434
41.213.786
47.659.451
49.089.235
50.042.424
50.995.613
55.938.835
57.617.001
58.735.777
59.854.554
46.667.026
48.067.037
49.000.377
49.933.718
53.531.882
55.137.839
56.208.476
57.279.114
61.164.003
62.998.923
64.222.203
65.445.483
2.581.332
2.658.772
2.710.399
2.762.025
3.613.865
3.722.281
3.794.558
3.866.836
5.692.657
5.863.437
5.977.290
6.091.143
23.053.110
23.744.703
24.205.765
24.666.828
29.917.966
30.815.505
31.413.865
32.012.224
42.894.833
44.181.678
45.039.575
45.897.471

SALURAN URIN SEDANG
SALURAN URIN BERAT
RINGAN
SEDANG
BERAT
&KURET RINGAN
KURET SEDANG
KURET BERAT

Regional 4
- 610 No
Kode
INA-CBG
598
P-8-05-i
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii
603
P-8-06-iii
604
P-8-07-i
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
614
P-8-11-ii
615
P-8-11-iii
616
P-8-12-i
617
P-8-12-ii
618
P-8-12-iii
619
P-8-13-i
620
P-8-13-ii
621
P-8-13-iii
622
P-8-14-i
623
P-8-14-ii
624
P-8-14-iii
625
P-8-15-i
Deskripsi (INA-CBG)
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
RINGAN
SEDANG
BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
ASPIRASI RINGAN
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
12.535.534
12.911.600
13.162.310
13.413.021
17.767.429
18.300.452
18.655.801
19.011.149
26.177.922
26.963.259
27.486.818
28.010.376
2.065.066
2.127.018
2.168.319
2.209.620
5.196.247
5.352.134
5.456.059
5.559.984
9.665.611
9.955.580
10.148.892
10.342.204
3.613.865
3.722.281
3.794.558
3.866.836
10.132.408
10.436.380
10.639.028
10.841.676
13.422.928
13.825.615
14.094.074
14.362.533
2.618.902
2.697.469
2.749.847
2.802.225
3.717.900
3.829.437
3.903.795
3.978.153
5.248.533
5.405.989
5.510.960
5.615.931
1.624.764
1.673.507
1.706.002
1.738.497
2.353.707
2.424.318
2.471.392
2.518.467
4.621.021
4.759.651
4.852.072
4.944.492
4.576.026
4.713.307
4.804.827
4.896.348
9.742.233
10.034.500
10.229.345
10.424.190
9.946.335
10.244.725
10.443.652
10.642.578
2.158.849
2.223.614
2.266.791
2.309.968
3.356.635
3.457.334
3.524.467
3.591.600
3.960.120
4.078.923
4.158.126
4.237.328
1.115.809
1.149.284
1.171.600
1.193.916
2.064.797
2.126.741
2.168.037
2.209.332
3.088.124
3.180.768
3.242.530
3.304.293
2.038.700
2.099.861
2.140.635
2.181.409
4.162.448
4.287.322
4.370.571
4.453.820
4.566.190
4.703.176
4.794.500
4.885.824
1.533.166
1.579.161
1.609.824
1.640.488
- 611 No
Kode
INA-CBG
626
P-8-15-ii
627
P-8-15-iii
628
P-8-16-i
629
P-8-16-ii
630
P-8-16-iii
631
P-8-17-i
632
P-8-17-ii
633
P-8-17-iii
634
S-4-10-i
635
S-4-10-ii
636
S-4-10-iii
637
S-4-11-i
638
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
3.064.396
3.156.327
3.217.615
3.278.903
3.599.607
3.707.595
3.779.587
3.851.580
1.387.878
1.429.514
1.457.271
1.485.029
1.968.764
2.027.826
2.067.202
2.106.577
2.555.552
2.632.218
2.683.329
2.734.441
915.996
943.476
961.796
980.116
3.042.629
3.133.908
3.194.761
3.255.613
6.141.353
6.325.594
6.448.421
6.571.248
1.532.986
1.578.975
1.609.635
1.640.295
1.916.232
1.973.719
2.012.044
2.050.369
2.490.773
2.565.496
2.615.312
2.665.127
958.116
986.860
1.006.022
1.025.184
S-4-11-ii
1.458.271
1.502.019
1.531.184
1.560.350
639
S-4-11-iii
2.359.227
2.430.004
2.477.189
2.524.373
640
S-4-12-i
1.149.739
1.184.232
1.207.226
1.230.221
641
S-4-12-ii
1.532.986
1.578.975
1.609.635
1.640.295
642
S-4-12-iii
2.994.043
3.083.864
3.143.745
3.203.626
1.532.986
1.578.975
1.609.635
1.640.295
2.709.975
2.791.275
2.845.474
2.899.674
5.517.854
5.683.390
5.793.747
5.904.104
934.020
962.041
980.721
999.402
1.984.172
2.043.697
2.083.381
2.123.064
3.762.697
3.875.578
3.950.832
4.026.086
706.408
727.600
741.728
755.857
1.333.233
1.373.230
1.399.894
1.426.559
1.726.846
1.778.651
1.813.188
1.847.725

ASPIRASI SEDANG
ASPIRASI BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT

PASIEN RINGAN
PASIEN SEDANG
PASIEN BERAT
Regional 4
643
S-4-13-i
644
S-4-13-ii
645
S-4-13-iii
646
S-4-14-i
647
S-4-14-ii
648
S-4-14-iii
649
S-4-15-i
650
S-4-15-ii
651
S-4-15-iii
652
S-4-16-i
LUKA BAKAR RINGAN
2.682.725
2.763.207
2.816.862
2.870.516
653
S-4-16-ii
LUKA BAKAR SEDANG
3.788.882
3.902.549
3.978.326
4.054.104
654
S-4-16-iii
LUKA BAKAR BERAT
6.765.637
6.968.606
7.103.919
7.239.232
1.430.482
1.473.396
1.502.006
1.530.615
1.916.232
1.973.719
2.012.044
2.050.369
3.124.795
3.218.539
3.281.035
3.343.531
655
S-4-17-i
656
S-4-17-ii
657
S-4-17-iii

- 612 No
Kode
INA-CBG
658
T-1-10-i
659
T-1-10-ii
660
T-1-10-iii
661
T-4-10-i
662
T-4-10-ii
663
T-4-10-iii
664
T-4-11-i
665
T-4-11-ii
666
T-4-11-iii
667
T-4-12-i
668
T-4-12-ii
669
T-4-12-iii
670
U-1-10-i
671
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
1.476.652
1.520.952
1.550.485
1.580.018
1.983.043
2.042.535
2.082.196
2.121.856
3.607.802
3.716.036
3.788.193
3.860.349
645.930
665.308
678.226
691.145
1.230.999
1.267.929
1.292.549
1.317.169
1.789.538
1.843.224
1.879.015
1.914.806
638.787
657.951
670.727
683.503
1.005.270
1.035.428
1.055.533
1.075.639
1.619.193
1.667.769
1.700.153
1.732.537
1.341.363
1.381.604
1.408.431
1.435.258
2.027.396
2.088.218
2.128.766
2.169.314
3.153.899
3.248.516
3.311.594
3.374.672
1.427.758
1.470.590
1.499.146
1.527.701
U-1-10-ii
2.913.427
3.000.830
3.059.099
3.117.367
672
U-1-10-iii
12.580.768
12.958.191
13.209.806
13.461.421
673
U-1-11-i
6.195.197
6.381.053
6.504.957
6.628.861
674
U-1-11-ii
8.260.263
8.508.071
8.673.276
8.838.482
675
U-1-11-iii
13.877.977
14.294.317
14.571.876
14.849.436
676
U-1-12-i
3.785.952
3.899.531
3.975.250
4.050.969
677
U-1-12-ii
9.292.796
9.571.580
9.757.436
9.943.292
678
U-1-12-iii
12.066.872
12.428.878
12.670.215
12.911.553
679
U-1-13-i
4.130.132
4.254.036
4.336.638
4.419.241
680
U-1-13-ii
4.659.909
4.799.706
4.892.904
4.986.103
681
U-1-13-iii
8.985.619
9.255.187
9.434.900
9.614.612
2.278.877
2.347.243
2.392.821
2.438.398
2.796.640
2.880.539
2.936.472
2.992.405
3.314.097
3.413.520
3.479.802
3.546.084

DOKTER RINGAN
DOKTER SEDANG
DOKTER BERAT

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)

Regional 4
682
U-1-14-i
683
U-1-14-ii
684
U-1-14-iii
685
U-1-15-i
1.338.471
1.378.625
1.405.395
1.432.164
686
U-1-15-ii
1.901.874
1.958.930
1.996.968
2.035.005
687
U-1-15-iii
3.747.719
3.860.151
3.935.105
4.010.060
U-1-20-i

3.462.042
3.565.903
3.635.144
3.704.385
688
- 613 No
Kode
INA-CBG
689
U-1-20-ii
690
U-1-20-iii
691
U-1-30-i
692
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
6.162.435
6.347.308
6.470.557
6.593.805
15.202.952
15.659.040
15.963.099
16.267.158
2.969.828
3.058.923
3.118.320
3.177.716
U-1-30-ii
4.009.268
4.129.546
4.209.732
4.289.917
693
U-1-30-iii
7.859.319
8.095.098
8.252.284
8.409.471
694
U-4-10-i
2.764.414
2.847.347
2.902.635
2.957.923
695
U-4-10-ii
6.929.806
7.137.700
7.276.296
7.414.892
696
U-4-10-iii
10.109.077
10.412.350
10.614.531
10.816.713
697
U-4-11-i
1.532.986
1.578.975
1.609.635
1.640.295
698
U-4-11-ii
2.299.479
2.368.463
2.414.453
2.460.442
699
U-4-11-iii
3.180.170
3.275.575
3.339.179
3.402.782
700
U-4-12-i
1.532.986
1.578.975
1.609.635
1.640.295
701
U-4-12-ii
1.787.108
1.840.722
1.876.464
1.912.206
702
U-4-12-iii
2.841.421
2.926.664
2.983.492
3.040.321
1.506.046
1.551.227
1.581.348
1.611.469
1.750.866
1.803.392
1.838.409
1.873.427
1.987.980
2.047.620
2.087.379
2.127.139


DAN TELINGA RINGAN
DAN TELINGA SEDANG
DAN TELINGA BERAT

Regional 4
703
U-4-13-i
704
U-4-13-ii
705
U-4-13-iii
706
U-4-14-i
1.916.232
1.973.719
2.012.044
2.050.369
707
U-4-14-ii
2.299.479
2.368.463
2.414.453
2.460.442
708
U-4-14-iii
3.852.026
3.967.587
4.044.627
4.121.668
709
U-4-15-i
1.532.986
1.578.975
1.609.635
1.640.295
710
U-4-15-ii
1.916.232
1.973.719
2.012.044
2.050.369
711
U-4-15-iii
2.683.245
2.763.743
2.817.408
2.871.073
712
V-1-10-i
4.481.426
4.615.869
4.705.497
4.795.126
713
V-1-10-ii
5.162.664
5.317.544
5.420.798
5.524.051
714
V-1-10-iii
9.809.062
10.103.334
10.299.516
10.495.697
715
V-1-11-i
5.162.664
5.317.544
5.420.798
5.524.051
716
V-1-11-ii
5.761.620
5.934.469
6.049.701
6.164.934
717
V-1-11-iii
8.532.077
8.788.040
8.958.681
9.129.323
718
V-1-12-i
2.788.254
2.871.902
2.927.667
2.983.432
719
V-1-12-ii
10.655.780
10.975.453
11.188.569
11.401.685
720
V-1-12-iii
12.441.594
12.814.842
13.063.674
13.312.506
721
V-1-13-i
4.226.089
4.352.872
4.437.394
4.521.916
722
V-1-13-ii
8.030.782
8.271.706
8.432.321
8.592.937

KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

- 614 No
Kode
INA-CBG
723
V-1-13-iii
724
V-1-14-i
725
V-1-14-ii
726
V-1-14-iii
727
V-1-15-i
728
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
12.390.395
12.762.107
13.009.914
13.257.722
5.094.600
5.247.438
5.349.330
5.451.222
7.409.659
7.631.949
7.780.142
7.928.335
10.072.353
10.374.524
10.575.971
10.777.418
2.401.820
2.473.875
2.521.911
2.569.948
V-1-15-ii
4.575.000
4.712.250
4.803.750
4.895.250
729
V-1-15-iii
8.042.762
8.284.045
8.444.900
8.605.756
730
V-4-10-i
3.867.537
3.983.563
4.060.914
4.138.264
731
V-4-10-ii
4.995.386
5.145.247
5.245.155
5.345.063
732
V-4-10-iii
9.547.059
9.833.470
10.024.412
10.215.353
733
V-4-11-i
1.966.787
2.025.791
2.065.127
2.104.462
734
V-4-11-ii
2.873.790
2.960.004
3.017.480
3.074.956
735
V-4-11-iii
4.741.564
4.883.811
4.978.642
5.073.473
736
W-1-01-i
5.783.318
5.956.817
6.072.484
6.188.150
737
W-1-01-ii
6.965.732
7.174.704
7.314.018
7.453.333
738
W-1-01-iii
15.385.918
15.847.495
16.155.214
16.462.932
739
W-1-10-i
1.610.647
1.658.966
1.691.179
1.723.392
740
W-1-10-ii
3.005.732
3.095.904
3.156.018
3.216.133
741
W-1-10-iii
4.916.423
5.063.916
5.162.244
5.260.573
742
W-1-11-i
1.672.927
1.723.114
1.756.573
1.790.031
743
W-1-11-ii
3.226.451
3.323.244
3.387.773
3.452.302
744
W-1-11-iii
6.195.197
6.381.053
6.504.957
6.628.861
745
W-1-12-i
1.520.105
1.565.708
1.596.111
1.626.513
746
W-1-12-ii
1.728.331
1.780.180
1.814.747
1.849.314
747
W-1-12-iii
2.654.934
2.734.582
2.787.680
2.840.779
748
W-1-13-i
1.809.285
1.863.563
1.899.749
1.935.934
749
W-1-13-ii
1.964.362
2.023.292
2.062.580
2.101.867
750
W-1-13-iii
2.638.500
2.717.655
2.770.425
2.823.195
751
W-1-20-i
4.929.785
5.077.678
5.176.274
5.274.870
752
W-1-20-ii
6.934.482
7.142.517
7.281.206
7.419.896
753
W-1-20-iii
8.760.206
9.023.012
9.198.216
9.373.420
W-1-30-i

RINGAN
2.691.168
2.771.903
2.825.727
2.879.550
754

NON KOMPLEK (BERAT)

RINGAN
SEDANG
BERAT

SERVIK RINGAN
SERVIK SEDANG
SERVIK BERAT
ENDOSKOP RINGAN
ENDOSKOP SEDANG
ENDOSKOP BERAT
- 615 No
Kode
INA-CBG
755
W-1-30-ii
756
W-1-30-iii
757
W-4-10-i
758
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
4.292.553
4.421.329
4.507.180
4.593.031
11.414.953
11.757.402
11.985.701
12.214.000
2.006.937
2.067.145
2.107.284
2.147.423
W-4-10-ii
2.712.601
2.793.979
2.848.231
2.902.483
759
W-4-10-iii
6.131.944
6.315.902
6.438.541
6.561.180
760
W-4-11-i
1.916.232
1.973.719
2.012.044
2.050.369
761
W-4-11-ii
3.065.972
3.157.951
3.219.270
3.280.590
762
W-4-11-iii
3.726.064
3.837.846
3.912.368
3.986.889
1.532.986
1.578.975
1.609.635
1.640.295
2.107.856
2.171.091
2.213.248
2.255.406
2.350.025
2.420.526
2.467.526
2.514.527

SEDANG
BERAT

Regional 4
763
W-4-12-i
764
W-4-12-ii
765
W-4-12-iii
766
W-4-13-i
ABORTUS RINGAN
840.708
865.929
882.743
899.557
767
W-4-13-ii
ABORTUS SEDANG
1.149.739
1.184.232
1.207.226
1.230.221
768
W-4-13-iii
ABORTUS BERAT
1.532.986
1.578.975
1.609.635
1.640.295
769
W-4-14-i
1.149.739
1.184.232
1.207.226
1.230.221
770
W-4-14-ii
1.478.751
1.523.113
1.552.688
1.582.263
771
W-4-14-iii
1.860.721
1.916.542
1.953.757
1.990.971
772
W-4-15-i
958.749
987.511
1.006.686
1.025.861
773
W-4-15-ii
1.066.311
1.098.301
1.119.627
1.140.953
774
W-4-15-iii
1.476.409
1.520.702
1.550.230
1.579.758
775
W-4-16-i
1.149.739
1.184.232
1.207.226
1.230.221
776
W-4-16-ii
1.532.986
1.578.975
1.609.635
1.640.295
777
W-4-16-iii
2.090.018
2.152.718
2.194.519
2.236.319
778
W-4-17-i
939.056
967.228
986.009
1.004.790
779
W-4-17-ii
1.532.986
1.578.975
1.609.635
1.640.295
780
W-4-17-iii
2.900.104
2.987.108
3.045.110
3.103.112
781
Z-4-10-i
REHABILITASI RINGAN
2.630.422
2.709.335
2.761.943
2.814.552
782
Z-4-10-ii
REHABILITASI SEDANG
3.491.506
3.596.251
3.666.081
3.735.911
783
Z-4-10-iii
REHABILITASI BERAT
4.960.017
5.108.818
5.208.018
5.307.218
784
Z-4-11-i
2.296.069
2.364.951
2.410.873
2.456.794
785
Z-4-11-ii
2.763.960
2.846.879
2.902.158
2.957.437
786
Z-4-11-iii
4.373.076
4.504.268
4.591.730
4.679.191
1.149.739
1.184.232
1.207.226
1.230.221
2.342.556
2.412.833
2.459.684
2.506.535
2.977.018
3.066.329
3.125.869
3.185.409
787
Z-4-12-i
788
Z-4-12-ii
789
Z-4-12-iii

- 616 b. RawatJalan
No
Kode
INA-CBG
B-2-10-0
B-2-11-0
Deskripsi (INA-CBG)
LAPAROSKOPI
PANKREAS
LAPAROSKOPI
EMPEDU
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
775.006
798.256
813.756
829.256
1.005.304
1.035.463
1.055.569
1.075.675
1.869.494
1.925.579
1.962.969
2.000.359
1.544.956
1.591.304
1.622.204
1.653.103
1.290.677
1.329.398
1.355.211
1.381.025
452.517
466.093
475.143
484.193
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
1.009.054
1.039.326
1.059.507
1.079.688
B-3-12-0

207.327
213.547
217.694
221.840
C-3-10-0
565.560
582.527
593.838
605.149
10
C-3-11-0

KANDUNG KEMIH
894.454
921.288
939.177
957.066
11
C-3-12-0
202.771
208.854
212.909
216.965
12
C-3-13-0
196.904
202.812
206.750
210.688
13
C-3-14-0
1.676.251
1.726.538
1.760.063
1.793.588
14
C-3-15-0
1.536.351
1.582.441
1.613.168
1.643.895
15
C-3-16-0
348.407
358.860
365.828
372.796
16
C-3-17-0

LEHER
231.123
238.057
242.679
247.302
17
C-3-18-0
102.470
105.544
107.594
109.643
18
C-3-19-0

MYELOMA ATAU TESTIS
144.913
149.261
152.159
155.057
19
C-3-20-0
2.885.957
2.972.536
3.030.255
3.087.974
20
C-3-21-0
165.372
170.333
173.641
176.948
21
C-3-22-0
726.072
747.854
762.376
776.897
22
C-3-23-0
117.608
121.136
123.488
125.840
23
D-2-10-0

TULANG
996.390
1.026.282
1.046.209
1.066.137
24
D-2-11-0
PROSEDUR LIMPA
1.247.650
1.285.080
1.310.033
1.334.986
1.046.425
1.077.818
1.098.747
1.119.675
229.659
236.549
241.142
245.735
166.348
171.338
174.665
177.992
431.886
444.843
453.481
462.118
256.192
263.877
269.001
274.125
185.730
191.302
195.017
198.731
185.730
191.302
195.017
198.731
25
D-2-21-0
26
D-2-22-0
27
D-3-10-0
28
D-3-11-0
29
E-2-10-0
30
E-2-21-0
31
E-2-22-0

OVARIUM
GASTROINTESTINAL
GINJAL ATAU PROSTAT

TYMUS
TYMUS
TULANG
PEMBENTUK DARAH
PARATIROID
THYROGLOSSAL
- 617 No
Kode
INA-CBG
32
E-3-10-0
33
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3

ENDOKRIN
215.992
222.472
226.792
231.112
F-3-10-0
TERAPI SHOCK
301.302
310.341
316.367
322.393
34
F-5-10-0
369.193
380.268
387.652
395.036
35
F-5-11-0
TERAPI KELOMPOK
243.449
250.752
255.621
260.490
36
F-5-12-0
311.534
320.880
327.110
333.341
37
F-5-13-0
263.848
271.764
277.041
282.318
38
F-5-14-0
177.007
182.317
185.857
189.397
39
F-5-15-0
166.055
171.037
174.358
177.679
40
F-5-16-0
172.963
178.151
181.611
185.070
41
G-2-10-0
145.648
150.017
152.930
155.843
42
G-2-11-0
1.262.536
1.300.412
1.325.663
1.350.914
43
G-2-12-0

EKSTRAKRANIAL
1.829.726
1.884.618
1.921.212
1.957.807
44
G-2-13-0
448.873
462.339
471.316
480.294
45
G-2-21-0
818.668
843.228
859.601
875.975
46
G-2-22-0
743.011
765.301
780.161
795.022
47
G-2-31-0
1.226.033
1.262.814
1.287.334
1.311.855
48
G-2-32-0
628.463
647.317
659.886
672.456
49
G-3-10-0
249.441
256.924
261.913
266.902
50
G-3-11-0
332.208
342.174
348.818
355.462
51
G-3-12-0
544.328
560.658
571.544
582.431
52
G-3-13-0
544.390
560.722
571.610
582.497
53
H-2-21-0
714.431
735.864
750.153
764.441
54
H-2-22-0
185.730
191.302
195.017
198.731
55
H-2-23-0
185.730
191.302
195.017
198.731
56
H-2-31-0
1.183.396
1.218.898
1.242.565
1.266.233
57
H-2-32-0
123.164
126.859
129.322
131.785
58
H-2-33-0
185.730
191.302
195.017
198.731
59
H-2-34-0
530.900
546.827
557.445
568.063
60
H-2-35-0
174.944
180.192
183.691
187.190
61
H-2-36-0
944.305
972.634
991.520
1.010.406
62
H-2-37-0

1.005.254
1.035.412
1.055.517
1.075.622
63
H-3-10-0
349.755
360.248
367.243
374.238

AKUT
MENTAL
PROSEDUR KRANIOTOMI

MATA
MATA
MATA
MATA
MATA
Regional 4
- 618 No
Kode
INA-CBG
64
H-3-11-0
65
H-3-12-0
66
H-3-13-0
67
I-2-11-0
68
I-2-12-0
69
I-2-13-0
70
I-2-14-0
71
I-2-15-0
72
I-2-16-0
73
I-2-17-0
74
I-2-21-0
75
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
183.932
189.450
193.129
196.808
192.035
197.796
201.636
205.477
186.454
192.048
195.777
199.506
2.150.214
2.214.720
2.257.725
2.300.729
1.511.835
1.557.190
1.587.427
1.617.663
1.921.451
1.979.095
2.017.524
2.055.953
3.400.560
3.502.576
3.570.588
3.638.599
204.503
210.638
214.728
218.818
2.147.884
2.212.320
2.255.278
2.298.235
708.096
729.338
743.500
757.662
1.657.861
1.707.597
1.740.754
1.773.911
I-2-22-0
1.561.166
1.608.001
1.639.225
1.670.448
76
I-2-23-0
319.488
329.073
335.462
341.852
77
I-2-31-0
2.484.766
2.559.309
2.609.004
2.658.700
78
I-2-32-0
3.249.197
3.346.672
3.411.656
3.476.640
79
I-2-41-0
2.178.626
2.243.985
2.287.558
2.331.130
80
I-2-42-0

LAIN
2.533.013
2.609.004
2.659.664
2.710.324
81
I-3-10-0
PROSEDUR RESUSITASI
321.544
331.190
337.621
344.052
82
I-3-11-0
169.710
174.801
178.195
181.590
83
I-3-12-0
986.290
1.015.879
1.035.605
1.055.331
84
I-3-13-0
323.936
333.654
340.133
346.611
85
I-3-14-0
207.632
213.861
218.013
222.166
86
I-3-15-0
183.932
189.450
193.129
196.808
87
J-2-10-0
1.175.761
1.211.034
1.234.549
1.258.065
88
J-2-21-0
189.532
195.218
199.009
202.800
89
J-2-22-0
955.125
983.779
1.002.882
1.021.984
90
J-2-31-0
1.238.883
1.276.050
1.300.827
1.325.605
91
J-2-32-0
921.935
949.593
968.031
986.470
92
J-3-10-0
191.760
197.513
201.348
205.183
93
J-3-11-0

PADA DADA
541.879
558.136
568.973
579.811
94
J-3-12-0
209.354
215.634
219.822
224.009
95
J-3-13-0
308.117
317.360
323.522
329.685

MATA
TORASIK
ABDOMEN
PENGGANTIAN ALAT
DARAH VENA

PACU JANTUNG

KARDIOVASKULAR
PERNAFASAN
PENDEK
- 619 No
Kode
INA-CBG
96
J-3-14-0
97
J-3-15-0
98
J-3-16-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
327.099
336.912
343.454
349.996
286.840
295.445
301.182
306.919
327.099
336.912
343.454
349.996
191.760
197.513
201.348
205.183
534.595
550.633
561.325
572.017
1.141.578
1.175.826
1.198.657
1.221.489
876.309
902.598
920.124
937.650
1.426.240
1.469.027
1.497.552
1.526.077
185.730
191.302
195.017
198.731
185.730
191.302
195.017
198.731
2.387.075
2.458.687
2.506.429
2.554.170
802.652
826.732
842.785
858.838
185.730
191.302
195.017
198.731

PERNAFASAN
KECIL
Regional 4
99
J-3-17-0
100
K-2-10-0
101
K-2-11-0
102
K-2-12-0

103
K-2-13-0
104
K-2-14-0
105
K-2-21-0
106
K-2-22-0
107
K-2-31-0
108
K-2-32-0
109
K-2-41-0
884.138
910.662
928.345
946.027
110
K-2-42-0

252.609
260.187
265.240
270.292
111
K-2-51-0
585.883
603.460
615.177
626.895
112
K-2-52-0
319.488
329.073
335.462
341.852
113
K-2-53-0
185.730
191.302
195.017
198.731
114
K-3-10-0

GASTROINTESTINAL
353.432
364.035
371.104
378.172
115
K-3-11-0
212.482
218.856
223.106
227.355
116
K-3-12-0
215.483
221.948
226.257
230.567
117
K-3-13-0
185.730
191.302
195.017
198.731
118
K-3-14-0
497.761
512.694
522.649
532.604
119
K-3-15-0
240.376
247.587
252.394
257.202
120
K-3-16-0
318.513
328.068
334.439
340.809
121
L-2-21-0
1.095.060
1.127.911
1.149.813
1.171.714
122
L-2-22-0
701.925
722.983
737.022
751.060
123
L-2-31-0
316.814
326.318
332.655
338.991
124
L-2-32-0
319.488
329.073
335.462
341.852
125
L-2-41-0
956.669
985.369
1.004.502
1.023.636
126
L-2-42-0

214.565
221.002
225.294
229.585
127
L-2-51-0
1.432.283
1.475.252
1.503.897
1.532.543
128
L-2-52-0

1.095.744
1.128.616
1.150.531
1.172.446

FEMORALIS
USUS BESAR
ATAS
ATAS

GASTROINTESTINAL
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
- 620 No
Kode
INA-CBG
129
L-2-53-0
130
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3

185.730
191.302
195.017
198.731
L-3-10-0
252.609
260.187
265.240
270.292
131
L-3-11-0
245.301
252.660
257.566
262.472
132
L-3-12-0
186.820
192.425
196.161
199.897
133
M-2-10-0
1.465.330
1.509.290
1.538.597
1.567.903
134
M-2-21-0
1.312.305
1.351.674
1.377.920
1.404.166
135
M-2-22-0
319.488
329.073
335.462
341.852
136
M-2-31-0
PROSEDUR BUNION
797.093
821.006
836.948
852.890
137
M-2-32-0
252.609
260.187
265.240
270.292
138
M-2-41-0

TULANG
252.609
260.187
265.240
270.292
139
M-2-42-0
87.056
89.668
91.409
93.150
140
M-2-51-0
185.730
191.302
195.017
198.731
141
M-2-52-0
185.730
191.302
195.017
198.731
142
M-2-61-0
PROSEDUR ARTROSKOPI
910.361
937.672
955.879
974.086
143
M-2-62-0
185.730
191.302
195.017
198.731
915.285
942.744
961.050
979.355
1.248.260
1.285.708
1.310.673
1.335.639
185.730
191.302
195.017
198.731
921.544
949.191
967.621
986.052
889.329
916.009
933.796
951.583

DAN WAJAH
PAHA
PAHA

TULANG
WAJAH
WAJAH
BAWAH
BAWAH
Regional 4
144
M-2-63-0
145
M-2-64-0
146
M-2-65-0
147
M-2-71-0
148
M-2-72-0
149
M-2-81-0
1.326.180
1.365.965
1.392.489
1.419.012
150
M-2-82-0
963.384
992.286
1.011.554
1.030.821
151
M-2-83-0
185.730
191.302
195.017
198.731
152
M-2-84-0
185.730
191.302
195.017
198.731
153
M-3-10-0
530.110
546.013
556.615
567.217
154
M-3-11-0
293.914
302.731
308.609
314.487
155
M-3-12-0
664.663
684.603
697.896
711.189
156
M-3-13-0
216.698
223.199
227.533
231.867
157
M-3-14-0

TERTUTUP
370.374
381.485
388.892
396.300
158
M-3-15-0
163.172
168.067
171.331
174.594
159
M-3-16-0

185.730
191.302
195.017
198.731
160
M-3-17-0
202.771
208.854
212.909
216.965
161
N-2-11-0
2.453.678
2.527.288
2.576.362
2.625.435

PERGELANGAN TANGAN
PERGELANGAN TANGAN
MUSKULOSKELETAL
SKELETAL
- 621 No
Kode
INA-CBG
162
N-2-12-0
163
N-2-21-0
164
N-2-22-0
165
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
1.419.428
1.462.011
1.490.400
1.518.788
1.411.946
1.454.305
1.482.544
1.510.783
319.488
329.073
335.462
341.852
N-2-23-0
319.488
329.073
335.462
341.852
166
N-2-24-0
1.032.478
1.063.452
1.084.102
1.104.751
167
N-2-31-0
869.179
895.254
912.638
930.022
168
N-2-32-0
319.488
329.073
335.462
341.852
169
N-2-41-0
319.488
329.073
335.462
341.852
170
N-2-42-0
540.315
556.525
567.331
578.138
171
N-3-10-0
319.488
329.073
335.462
341.852
172
N-3-11-0
370.172
381.278
388.681
396.085
173
N-3-12-0
286.049
294.630
300.351
306.072
174
N-3-13-0
319.488
329.073
335.462
341.852
175
N-3-14-0
274.902
283.149
288.647
294.145
176
N-3-15-0
704.918
726.066
740.164
754.262
177
O-7-10-0
117.691
121.222
123.575
125.929
178
O-7-11-0
648.155
667.600
680.563
693.526
179
O-7-12-0
236.015
243.096
247.816
252.536
180
O-7-13-0
131.167
135.102
137.725
140.348
181
P-9-10-0
174.944
180.192
183.691
187.190
182
P-9-11-0
174.944
180.192
183.691
187.190
183
P-9-12-0
174.944
180.192
183.691
187.190
184
P-9-13-0
174.944
180.192
183.691
187.190
185
P-9-14-0
174.944
180.192
183.691
187.190
186
P-9-15-0
111.513
114.858
117.088
119.319
187
P-9-16-0
174.944
180.192
183.691
187.190
188
P-9-17-0
174.191
179.417
182.901
186.385
189
Q-5-10-0
228.007
234.848
239.408
243.968
190
Q-5-11-0
170.885
176.012
179.430
182.847
191
Q-5-12-0
GIGI
150.614
155.132
158.144
161.157
192
Q-5-13-0
MEDICAL CHECK-UP
114.460
117.894
120.183
122.472
193
Q-5-14-0
125.943
129.722
132.240
134.759


DAN URETHRA
URETHRA
TRANSURETHRA
TRANSURETHRA
SALURAN KEMIH
KEMIH
KEMIH
PROSEDUR DIALISIS
CAESAR
VAGINAL/JALAN LAHIR

ASPIRASI
Regional 4
- 622 No
Kode
INA-CBG
194
Q-5-15-0
195
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
86.611
89.209
90.942
92.674
Q-5-16-0
VAKSINASI
97.891
100.827
102.785
104.743
196
Q-5-17-0
PASANG INFUS
84.673
87.213
88.906
90.600
197
Q-5-18-0
159.381
164.162
167.350
170.537
198
Q-5-19-0
178.178
183.523
187.087
190.651
199
Q-5-20-0
ABORSI MENGANCAM
119.427
123.010
125.398
127.787
200
Q-5-21-0
ABORSI
117.800
121.334
123.690
126.046
201
Q-5-22-0
125.943
129.722
132.240
134.759
202
Q-5-23-0
154.188
158.813
161.897
164.981
203
Q-5-24-0
105.308
108.467
110.573
112.680
204
Q-5-25-0
164.226
169.153
172.437
175.722
205
Q-5-26-0
BRONKIAL AKUT
239.997
247.197
251.997
256.797
206
Q-5-27-0
165.423
170.386
173.694
177.003
207
Q-5-28-0
134.236
138.264
140.948
143.633
208
Q-5-29-0

JANTUNG LAIN-LAIN
380.046
391.447
399.048
406.649
209
Q-5-30-0
440.432
453.645
462.453
471.262
210
Q-5-31-0
FRAKTUR
157.128
161.842
164.985
168.127
211
Q-5-32-0
SALURAN KEMIH AKUT
181.990
187.450
191.090
194.729
212
Q-5-33-0
HEMATOLOGI AKUT
190.543
196.259
200.070
203.881
213
Q-5-34-0
INFEKSI VIRUS HIV
270.680
278.800
284.214
289.627
214
Q-5-35-0
INFEKSI AKUT
306.943
316.152
322.291
328.430
215
Q-5-36-0
357.456
368.179
375.328
382.477
216
Q-5-37-0

SHOCK
182.321
187.790
191.437
195.083
217
Q-5-38-0
PARU AKUT
251.024
258.554
263.575
268.595
218
Q-5-39-0
155.586
160.253
163.365
166.477
219
Q-5-40-0
152.654
157.234
160.287
163.340
220
Q-5-41-0
211.328
217.668
221.895
226.121
221
Q-5-42-0
165.690
170.660
173.974
177.288
222
Q-5-43-0
238.603
245.761
250.533
255.305
223
Q-5-44-0
194.733
200.575
204.470
208.364
224
T-2-10-0

TERAPI DETOKSIKASI
101.005
104.035
106.055
108.075
225
U-2-10-0
1.348.022
1.388.463
1.415.423
1.442.384
226
U-2-11-0

LEHER
1.602.274
1.650.343
1.682.388
1.714.434
227
U-2-12-0
176.292
181.581
185.107
188.632
- 623 No
Kode
INA-CBG
228
U-2-13-0
229
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
231.123
238.057
242.679
247.302
U-2-14-0
429.322
442.202
450.788
459.375
230
U-2-15-0
243.931
251.249
256.128
261.007
231
U-2-21-0
284.142
292.666
298.349
304.032
232
U-2-22-0
548.985
565.455
576.434
587.414
233
U-2-23-0
719.348
740.928
755.315
769.702
234
U-2-24-0
606.254
624.442
636.567
648.692
235
U-2-25-0
231.123
238.057
242.679
247.302
236
U-2-31-0
185.730
191.302
195.017
198.731
237
U-2-32-0
231.123
238.057
242.679
247.302
238
U-3-10-0
220.966
227.595
232.014
236.434
239
U-3-11-0
234.597
241.635
246.327
251.019
240
U-3-12-0
103.738
106.851
108.925
111.000
241
U-3-13-0
228.025
234.866
239.427
243.987
242
U-3-14-0
209.508
215.793
219.984
224.174
243
U-3-15-0
182.710
188.191
191.845
195.499
244
U-3-16-0
PROSEDUR PADA GIGI
206.063
212.245
216.367
220.488
245
V-2-10-0

PROSTAT
2.010.387
2.070.699
2.110.907
2.151.114
246
V-2-11-0
226.721
233.522
238.057
242.591
723.497
745.202
759.672
774.142
319.488
329.073
335.462
341.852
319.488
329.073
335.462
341.852

(RHINOPLASTY)

RONGGA HIDUNG
TENGGOROKAN
PROSEDUR PADA PENIS

SKROTUM
SKROTUM
TRANSURETHRAL
Regional 4
247
V-2-12-0
248
V-2-13-0
249
V-2-14-0
250
V-2-15-0
SIRKUMSISI/SUNAT
174.944
180.192
183.691
187.190
251
V-3-10-0
364.857
375.802
383.100
390.397
252
V-3-11-0
771.861
795.017
810.454
825.891
253
V-3-12-0
445.616
458.984
467.897
476.809
254
W-2-10-0
163.172
168.067
171.331
174.594
255
W-2-11-0
417.007
429.518
437.858
446.198
256
W-2-12-0
771.861
795.017
810.454
825.891
257
W-2-13-0
123.793
127.507
129.982
132.458
258
W-2-21-0
1.551.647
1.598.196
1.629.229
1.660.262
259
W-2-22-0
163.172
168.067
171.331
174.594

PROSEDUR ABORSI
RAHIM & LEHER RAHIM
TERHALANG/TERGANGGU
TERHALANG/TERGANGGU
PANGGUL TERBUKA
PANGGUL TERBUKA
- 624 No
Kode
INA-CBG
260
W-2-23-0
Deskripsi (INA-CBG)
JALAN LAHIR
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
544.514
560.849
571.739
582.630
1.787.473
1.841.097
1.876.846
1.912.596
1.253.636
1.291.245
1.316.317
1.341.390
261
W-2-31-0
262
W-2-32-0
263
W-2-33-0
532.812
548.796
559.452
570.109
264
W-2-34-0
181.219
186.655
190.280
193.904
265
W-3-10-0
440.431
453.644
462.453
471.262
266
W-3-11-0
352.068
362.630
369.672
376.713
267
W-3-12-0
163.172
168.067
171.331
174.594
268
Z-3-10-0
1.847.327
1.902.747
1.939.693
1.976.640
269
Z-3-11-0

EMPEDU
1.411.946
1.454.305
1.482.544
1.510.783
270
Z-3-12-0
235.761
242.834
247.549
252.264
271
Z-3-13-0

LAIN-LAIN
1.438.678
1.481.838
1.510.611
1.539.385
272
Z-3-14-0
DIAGNOSTIK TIDUR
284.471
293.005
298.695
304.384
273
Z-3-15-0
185.730
191.302
195.017
198.731
274
Z-3-16-0

(MRI)
596.137
614.022
625.944
637.867
275
Z-3-17-0
PENGOBATAN NUKLIR
250.271
257.780
262.785
267.790
276
Z-3-18-0
CT-SCAN KEPALA
241.132
248.366
253.188
258.011
277
Z-3-19-0
CT SCAN LAIN-LAIN
250.971
258.500
263.520
268.539
278
Z-3-20-0
170.692
175.812
179.226
182.640
279
Z-3-21-0
163.172
168.067
171.331
174.594
280
Z-3-22-0
183.962
189.481
193.160
196.839
281
Z-3-23-0
191.612
197.361
201.193
205.025
282
Z-3-24-0
376.480
387.775
395.304
402.834
283
Z-3-25-0
167.684
172.714
176.068
179.422
284
Z-3-26-0
189.516
195.201
198.992
202.782
285
Z-3-27-0
PERAWATAN LUKA
180.936
186.364
189.983
193.602
286
Z-3-28-0
IMAGING PAYUDARA
185.730
191.302
195.017
198.731
287
Z-3-29-0
IMAGING LAIN-LAIN
535.308
551.367
562.073
572.779
288
Z-3-30-0
FOTOTERAPI
90.340
93.050
94.857
96.664
- 625 IV.
TARIF INA-CBG RUMAH SAKIT UMUM DAN KHUSUS KELAS C

TAHUN 2012
A. RUMAH SAKIT UMUM KELAS C
1. RawatInap
No
Kode
INA-CBG
A-4-10-i
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
SEPTIKEMIA RINGAN
1.630.782
1.645.459
1.655.244
1.665.029
A-4-10-ii
SEPTIKEMIA SEDANG
1.866.808
1.883.609
1.894.810
1.906.011
A-4-10-iii
SEPTIKEMIA BERAT
2.926.802
2.953.143
2.970.704
2.988.265
A-4-11-i
2.930.897
2.957.275
2.974.860
2.992.445
A-4-11-ii

SEDANG
4.527.897
4.568.648
4.595.815
4.622.983
A-4-11-iii
7.406.650
7.473.310
7.517.749
7.562.189
A-4-12-i
DEMAM RINGAN
1.149.740
1.160.087
1.166.986
1.173.884
A-4-12-ii
DEMAM SEDANG
1.649.053
1.663.894
1.673.788
1.683.683
A-4-12-iii
DEMAM BERAT
1.887.220
1.904.205
1.915.528
1.926.851
10
A-4-13-i
1.437.175
1.450.109
1.458.732
1.467.355
11
A-4-13-ii
1.724.610
1.740.131
1.750.479
1.760.826
12
A-4-13-iii
2.096.059
2.114.924
2.127.500
2.140.076
1.149.740
1.160.087
1.166.986
1.173.884
1.826.027
1.842.461
1.853.417
1.864.373
2.079.336
2.098.050
2.110.527
2.123.003

LAIN-LAIN RINGAN
LAIN-LAIN SEDANG
LAIN-LAIN BERAT
13
A-4-14-i
14
A-4-14-ii
15
A-4-14-iii
16
A-4-15-i
INFEKSI HIV RINGAN
1.724.610
1.740.131
1.750.479
1.760.826
17
A-4-15-ii
INFEKSI HIV SEDANG
2.586.914
2.610.196
2.625.718
2.641.239
18
A-4-15-iii
INFEKSI HIV BERAT
3.597.788
3.630.168
3.651.755
3.673.342
19
B-1-01-i
19.119.985
19.292.065
19.406.785
19.521.505
20
B-1-01-ii
21.094.455
21.284.305
21.410.872
21.537.439
21
B-1-01-iii
37.004.016
37.337.052
37.559.076
37.781.100
22
B-1-10-i
2.478.841
2.501.151
2.516.024
2.530.897
23
B-1-10-ii
6.317.281
6.374.137
6.412.041
6.449.944
24
B-1-10-iii
10.995.887
11.094.850
11.160.826
11.226.801
1.694.612
1.709.863
1.720.031
1.730.199
4.253.636
4.291.918
4.317.440
4.342.962
5.333.003
5.381.000
5.412.998
5.444.996
3.614.668
3.647.200
3.668.888
3.690.576
25
B-1-11-i
26
B-1-11-ii
27
B-1-11-iii
28
B-1-12-i

(RINGAN)
(SEDANG)
(BERAT)
LAPAROSKOPIK RINGAN
- 626 No
Kode
INA-CBG
29
B-1-12-ii
30
B-1-12-iii
31
B-1-13-i
32
B-1-13-ii
33
B-1-13-iii
34
B-1-14-i
35
B-1-14-ii
36
B-1-14-iii
37
B-4-10-i
38
B-4-10-ii
39
B-4-10-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
7.747.118
7.816.842
7.863.325
7.909.807
9.428.534
9.513.391
9.569.962
9.626.534
2.368.612
2.389.929
2.404.141
2.418.352
3.858.124
3.892.848
3.915.996
3.939.145
5.687.958
5.739.150
5.773.277
5.807.405
3.216.408
3.245.355
3.264.654
3.283.952
3.577.295
3.609.490
3.630.954
3.652.418
5.596.252
5.646.618
5.680.196
5.713.773
899.523
907.619
913.016
918.413
1.437.175
1.450.109
1.458.732
1.467.355
2.197.269
2.217.045
2.230.228
2.243.412
2.172.701
2.192.255
2.205.291
2.218.327
3.303.048
3.332.775
3.352.593
3.372.412
3.557.497
3.589.514
3.610.859
3.632.204
1.906.396
1.923.553
1.934.992
1.946.430
2.702.800
2.727.126
2.743.342
2.759.559
5.253.135
5.300.413
5.331.932
5.363.451
1.724.610
1.740.131
1.750.479
1.760.826
2.691.348
2.715.570
2.731.718
2.747.866
4.084.895
4.121.659
4.146.168
4.170.678
1.724.610
1.740.131
1.750.479
1.760.826
2.012.044
2.030.153
2.042.225
2.054.297
2.684.270
2.708.428
2.724.534
2.740.639

LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT
LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT

PANCREAS RINGAN
PANCREAS SEDANG
PANCREAS BERAT
(RINGAN)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT
40
B-4-11-i
41
B-4-11-ii
42
B-4-11-iii
43
B-4-12-i
44
B-4-12-ii
45
B-4-12-iii
46
B-4-13-i
47
B-4-13-ii
48
B-4-13-iii
49
B-4-14-i
50
B-4-14-ii
51
B-4-14-iii
52
C-4-10-i
1.679.422
1.694.536
1.704.613
1.714.689
53
C-4-10-ii
3.262.940
3.292.306
3.311.884
3.331.462
54
C-4-10-iii
LEUKEMIA AKUT BERAT
5.461.263
5.510.415
5.543.182
5.575.950
55
C-4-11-i
1.724.610
1.740.131
1.750.479
1.760.826
56
C-4-11-ii
2.299.479
2.320.175
2.333.972
2.347.768
57
C-4-11-iii
3.909.384
3.944.569
3.968.025
3.991.481
58
C-4-12-i
RADIOTERAPI RINGAN
1.149.740
1.160.087
1.166.986
1.173.884
59
C-4-12-ii
RADIOTERAPI SEDANG
3.165.580
3.194.071
3.213.064
3.232.058
60
C-4-12-iii
RADIOTERAPI BERAT
6.426.763
6.484.603
6.523.164
6.561.725
- 627 No
Kode
INA-CBG
61
C-4-13-i
62
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
KEMOTERAPI RINGAN
1.149.740
1.160.087
1.166.986
1.173.884
C-4-13-ii
KEMOTERAPI SEDANG
2.299.479
2.320.175
2.333.972
2.347.768
63
C-4-13-iii
KEMOTERAPI BERAT
3.008.699
3.035.777
3.053.829
3.071.881
64
C-4-14-i
1.490.905
1.504.323
1.513.268
1.522.214
65
C-4-14-ii
2.178.605
2.198.213
2.211.284
2.224.356
66
C-4-14-iii
3.321.221
3.351.112
3.371.039
3.390.966
67
D-1-10-i
12.234.594
12.344.705
12.418.113
12.491.520
68
D-1-10-ii
18.634.225
18.801.933
18.913.738
19.025.543
69
D-1-10-iii
25.254.466
25.481.756
25.633.283
25.784.810
70
D-1-11-i
2.514.716
2.537.348
2.552.436
2.567.525
71
D-1-11-ii
6.558.840
6.617.869
6.657.222
6.696.575
72
D-1-11-iii
9.292.798
9.376.433
9.432.190
9.487.947
73
D-1-20-i
3.097.599
3.125.478
3.144.063
3.162.649
74
D-1-20-ii
6.969.598
7.032.325
7.074.142
7.115.960
75
D-1-20-iii
12.598.703
12.712.091
12.787.684
12.863.276
76
D-4-10-i
1.104.396
1.114.335
1.120.962
1.127.588
77
D-4-10-ii
2.229.982
2.250.052
2.263.432
2.276.812
78
D-4-10-iii
2.874.349
2.900.218
2.917.464
2.934.711
79
D-4-11-i
1.437.175
1.450.109
1.458.732
1.467.355
80
D-4-11-ii
2.419.579
2.441.355
2.455.873
2.470.390
81
D-4-11-iii
6.154.035
6.209.421
6.246.346
6.283.270
82
D-4-12-i
1.474.267
1.487.535
1.496.381
1.505.227
83
D-4-12-ii
2.044.953
2.063.358
2.075.627
2.087.897
84
D-4-12-iii
3.140.027
3.168.287
3.187.127
3.205.967
85
D-4-13-i
1.149.740
1.160.087
1.166.986
1.173.884
86
D-4-13-ii
1.724.610
1.740.131
1.750.479
1.760.826
87
D-4-13-iii
2.012.044
2.030.153
2.042.225
2.054.297
88
D-4-14-i
1.385.296
1.397.764
1.406.076
1.414.387
89
D-4-14-ii
3.234.328
3.263.436
3.282.842
3.302.248
90
D-4-14-iii
3.858.105
3.892.828
3.915.977
3.939.125
91
E-1-01-i
2.756.048
2.780.852
2.797.388
2.813.925
92
E-1-01-ii
3.610.160
3.642.652
3.664.312
3.685.973
93
E-1-01-iii
8.182.511
8.256.154
8.305.249
8.354.344

RINGAN
SEDANG
BERAT
TULANG RINGAN
TULANG SEDANG
TULANG BERAT


RINGAN
SEDANG
BERAT
- 628 No
Kode
INA-CBG
94
E-1-10-i
95
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.808.265
2.833.539
2.850.389
2.867.238
E-1-10-ii
3.408.574
3.439.252
3.459.703
3.480.154
96
E-1-10-iii
7.184.271
7.248.930
7.292.035
7.335.141
97
E-1-20-i
4.227.638
4.265.686
4.291.052
4.316.418
98
E-1-20-ii
5.662.237
5.713.198
5.747.171
5.781.144
99
E-1-20-iii
12.545.918
12.658.831
12.734.107
12.809.382
100
E-4-10-i
1.437.175
1.450.109
1.458.732
1.467.355
101
E-4-10-ii
2.043.965
2.062.360
2.074.624
2.086.888
102
E-4-10-iii
3.906.998
3.942.161
3.965.603
3.989.045
103
E-4-11-i
1.226.211
1.237.246
1.244.604
1.251.961
104
E-4-11-ii
2.319.780
2.340.658
2.354.576
2.368.495
105
E-4-11-iii
3.825.424
3.859.852
3.882.805
3.905.757
106
E-4-12-i
1.465.150
1.478.337
1.487.127
1.495.918
107
E-4-12-ii
2.545.242
2.568.149
2.583.421
2.598.692
108
E-4-12-iii
4.156.185
4.193.591
4.218.528
4.243.465
1.545.447
1.559.356
1.568.628
1.577.901
2.653.543
2.677.425
2.693.346
2.709.267
4.591.299
4.632.621
4.660.169
4.687.716

RINGAN
SEDANG
BERAT

RINGAN
SEDANG
BERAT
109
E-4-13-i
110
E-4-13-ii
111
E-4-13-iii
112
F-4-10-i
SCHIZOFRENIA RINGAN
1.889.601
1.906.607
1.917.945
1.929.283
113
F-4-10-ii
SCHIZOFRENIA SEDANG
2.098.463
2.117.349
2.129.940
2.142.530
114
F-4-10-iii
SCHIZOFRENIA BERAT
3.106.820
3.134.782
3.153.422
3.172.063
115
F-4-11-i
1.741.754
1.757.430
1.767.881
1.778.331
116
F-4-11-ii
2.029.309
2.047.573
2.059.749
2.071.925
117
F-4-11-iii
DEPRESI MAYOR BERAT
2.602.316
2.625.737
2.641.351
2.656.965

IMPULSE RINGAN
IMPULSE SEDANG
IMPULSE BERAT
862.305
870.065
875.239
880.413
1.231.249
1.242.330
1.249.718
1.257.105
2.670.988
2.695.027
2.711.053
2.727.079
118
F-4-12-i
119
F-4-12-ii
120
F-4-12-iii
121
F-4-13-i
1.407.602
1.420.271
1.428.716
1.437.162
122
F-4-13-ii
1.864.027
1.880.803
1.891.987
1.903.172
123
F-4-13-iii
2.403.425
2.425.056
2.439.476
2.453.897
124
F-4-14-i
DEPRESI RINGAN
985.322
994.190
1.000.101
1.006.013
125
F-4-14-ii
DEPRESI SEDANG
1.263.875
1.275.250
1.282.833
1.290.416
126
F-4-14-iii
DEPRESI BERAT
1.700.600
1.715.905
1.726.109
1.736.312
- 629 No
Kode
INA-CBG
127
F-4-15-i
128
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.171.491
1.182.035
1.189.064
1.196.092
F-4-15-ii
1.724.610
1.740.131
1.750.479
1.760.826
129
F-4-15-iii
2.271.417
2.291.859
2.305.488
2.319.116
130
F-4-16-i
2.523.163
2.545.871
2.561.010
2.576.149
131
F-4-16-ii
2.933.114
2.959.512
2.977.110
2.994.709
132
F-4-16-iii
3.915.217
3.950.454
3.973.945
3.997.437
133
F-4-17-i
582.568
587.812
591.307
594.802
134
F-4-17-ii
1.707.453
1.722.820
1.733.064
1.743.309
135
F-4-17-iii
1.821.726
1.838.122
1.849.052
1.859.983
136
F-4-18-i
2.186.992
2.206.675
2.219.797
2.232.919
137
F-4-18-ii
2.406.309
2.427.966
2.442.404
2.456.842
138
F-4-18-iii
3.709.536
3.742.922
3.765.179
3.787.436
139
F-4-19-i
1.677.217
1.692.312
1.702.375
1.712.438
140
F-4-19-ii
2.147.719
2.167.049
2.179.935
2.192.822
141
F-4-19-iii
2.673.939
2.698.005
2.714.048
2.730.092
142
G-1-01-i
5.332.230
5.380.220
5.412.214
5.444.207
143
G-1-01-ii
9.025.442
9.106.671
9.160.824
9.214.977
144
G-1-01-iii
17.472.249
17.629.499
17.734.332
17.839.166
145
G-1-10-i
2.661.052
2.685.001
2.700.968
2.716.934
146
G-1-10-ii
3.756.744
3.790.554
3.813.095
3.835.635
147
G-1-10-iii
4.452.544
4.492.617
4.519.332
4.546.047
148
G-1-11-i
3.069.603
3.097.229
3.115.647
3.134.065
149
G-1-11-ii
6.303.661
6.360.394
6.398.216
6.436.038
150
G-1-11-iii
13.199.292
13.318.086
13.397.282
13.476.477
151
G-1-12-i
2.387.247
2.408.732
2.423.055
2.437.379
152
G-1-12-ii
5.465.363
5.514.552
5.547.344
5.580.136
153
G-1-12-iii
9.639.703
9.726.460
9.784.298
9.842.136
154
G-1-13-i
629.591
635.258
639.035
642.813
155
G-1-13-ii
1.691.013
1.706.232
1.716.378
1.726.524
156
G-1-13-iii
3.815.638
3.849.979
3.872.872
3.895.766
157
G-1-20-i
3.008.134
3.035.207
3.053.256
3.071.305
158
G-1-20-ii
4.064.087
4.100.664
4.125.049
4.149.433
159
G-1-20-iii
9.950.440
10.039.994
10.099.696
10.159.399

RINGAN
SEDANG
BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

RINGAN
SEDANG
BERAT
- 630 No
Kode
INA-CBG
160
G-1-30-i
161
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.836.604
3.871.133
3.894.153
3.917.173
G-1-30-ii
10.013.904
10.104.029
10.164.112
10.224.196
162
G-1-30-iii
12.890.989
13.007.008
13.084.354
13.161.700
163
G-4-10-i
1.724.610
1.740.131
1.750.479
1.760.826
164
G-4-10-ii
2.012.044
2.030.153
2.042.225
2.054.297
165
G-4-10-iii
3.073.846
3.101.511
3.119.954
3.138.397
166
G-4-11-i
2.845.482
2.871.091
2.888.164
2.905.237
167
G-4-11-ii
3.300.759
3.330.466
3.350.271
3.370.075
168
G-4-11-iii
4.837.320
4.880.855
4.909.879
4.938.903
169
G-4-12-i
2.128.170
2.147.324
2.160.093
2.172.862
170
G-4-12-ii
2.681.494
2.705.628
2.721.717
2.737.806
171
G-4-12-iii
3.894.551
3.929.602
3.952.970
3.976.337
172
G-4-13-i
1.184.100
1.194.757
1.201.861
1.208.966
173
G-4-13-ii
2.012.044
2.030.153
2.042.225
2.054.297
174
G-4-13-iii
2.378.522
2.399.929
2.414.200
2.428.471
175
G-4-14-i
2.165.542
2.185.032
2.198.025
2.211.018
176
G-4-14-ii
3.563.047
3.595.114
3.616.493
3.637.871
177
G-4-14-iii
4.461.016
4.501.165
4.527.931
4.554.697
178
G-4-15-i
2.216.495
2.236.443
2.249.742
2.263.041
179
G-4-15-ii
2.678.302
2.702.407
2.718.476
2.734.546
180
G-4-15-iii
3.309.650
3.339.437
3.359.295
3.379.153
181
G-4-16-i
1.437.175
1.450.109
1.458.732
1.467.355
182
G-4-16-ii
2.149.308
2.168.651
2.181.547
2.194.443
183
G-4-16-iii
3.900.609
3.935.715
3.959.118
3.982.522
184
G-4-17-i
2.053.854
2.072.339
2.084.662
2.096.985
185
G-4-17-ii
2.548.923
2.571.863
2.587.157
2.602.450
186
G-4-17-iii
4.272.016
4.310.464
4.336.096
4.361.728
187
G-4-18-i
1.724.610
1.740.131
1.750.479
1.760.826
188
G-4-18-ii
2.472.792
2.495.047
2.509.883
2.524.720
189
G-4-18-iii
2.619.671
2.643.248
2.658.966
2.674.684

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
DEGENERATIF RINGAN
DEGENERATIF SEDANG
DEGENERATIF BERAT
RINGAN
SEDANG
BERAT
TRAUMATIK RINGAN
TRAUMATIK SEDANG
TRAUMATIK BERAT
DENGAN INFARK BERAT
TANPA INFARK RINGAN
TANPA INFARK SEDANG
TANPA INFARK BERAT

PERIFER RINGAN
PERIFER SEDANG
PERIFER BERAT
PERSARAFAN RINGAN
PERSARAFAN SEDANG
PERSARAFAN BERAT
- 631 No
Kode
INA-CBG
190
G-4-19-i
191
G-4-19-ii
192
G-4-19-iii
193
G-4-20-i
194
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.437.175
1.450.109
1.458.732
1.467.355
2.912.628
2.938.841
2.956.317
2.973.793
4.344.716
4.383.818
4.409.887
4.435.955
1.006.022
1.015.076
1.021.113
1.027.149
G-4-20-ii
1.428.553
1.441.410
1.449.981
1.458.552
195
G-4-20-iii
2.436.017
2.457.941
2.472.557
2.487.173
196
G-4-21-i
1.165.750
1.176.241
1.183.236
1.190.230
197
G-4-21-ii
2.414.384
2.436.114
2.450.600
2.465.086
198
G-4-21-iii
2.844.429
2.870.029
2.887.096
2.904.162
199
G-4-22-i
1.149.740
1.160.087
1.166.986
1.173.884
200
G-4-22-ii
1.437.175
1.450.109
1.458.732
1.467.355
201
G-4-22-iii
1.648.815
1.663.654
1.673.547
1.683.440
202
G-4-23-i
1.149.740
1.160.087
1.166.986
1.173.884
203
G-4-23-ii
1.437.175
1.450.109
1.458.732
1.467.355
204
G-4-23-iii
2.054.339
2.072.828
2.085.154
2.097.480
205
G-4-24-i
1.149.740
1.160.087
1.166.986
1.173.884
206
G-4-24-ii
1.437.175
1.450.109
1.458.732
1.467.355
207
G-4-24-iii
TRAUMA KEPALA BERAT
3.020.067
3.047.247
3.065.368
3.083.488
208
G-4-25-i
GEGAR OTAK RINGAN
1.092.477
1.102.309
1.108.864
1.115.419
209
G-4-25-ii
GEGAR OTAK SEDANG
1.375.453
1.387.832
1.396.085
1.404.337
210
G-4-25-iii
GEGAR OTAK BERAT
1.794.586
1.810.737
1.821.504
1.832.272
211
G-4-26-i
1.724.610
1.740.131
1.750.479
1.760.826
212
G-4-26-ii
2.012.044
2.030.153
2.042.225
2.054.297
213
G-4-26-iii
3.840.711
3.875.278
3.898.322
3.921.366
214
H-1-20-i
2.148.414
2.167.750
2.180.640
2.193.531
215
H-1-20-ii
3.917.876
3.953.137
3.976.644
4.000.152
216
H-1-20-iii
5.328.067
5.376.020
5.407.988
5.439.956
217
H-1-30-i
2.103.502
2.122.434
2.135.055
2.147.676
218
H-1-30-ii
2.397.992
2.419.574
2.433.962
2.448.350
219
H-1-30-iii
4.000.963
4.036.972
4.060.978
4.084.984
220
H-4-10-i
1.724.610
1.740.131
1.750.479
1.760.826
221
H-4-10-ii
2.874.349
2.900.218
2.917.464
2.934.711
222
H-4-10-iii
4.686.038
4.728.212
4.756.329
4.784.445

SEDANG

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)

RINGAN
SEDANG
- 632 No
Kode
INA-CBG
223
H-4-11-i
224
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.174.270
1.184.838
1.191.884
1.198.929
H-4-11-ii
1.312.071
1.323.880
1.331.752
1.339.625
225
H-4-11-iii
1.876.139
1.893.025
1.904.281
1.915.538
226
H-4-12-i
1.629.252
1.643.915
1.653.691
1.663.466
227
H-4-12-ii
2.206.929
2.226.791
2.240.032
2.253.274
228
H-4-12-iii
3.682.110
3.715.249
3.737.341
3.759.434
24.804.256
25.027.494
25.176.320
25.325.145
25.350.079
25.578.230
25.730.330
25.882.431
40.014.613
40.374.745
40.614.833
40.854.920
13.761.258
13.885.110
13.967.677
14.050.245
17.752.023
17.911.792
18.018.304
18.124.816
21.880.401
22.077.324
22.208.607
22.339.889
8.474.672
8.550.944
8.601.793
8.652.641
11.615.997
11.720.541
11.790.237
11.859.933
17.036.796
17.190.127
17.292.348
17.394.569
10.338.852
10.431.902
10.493.935
10.555.968
13.280.439
13.399.963
13.479.646
13.559.328
28.311.139
28.565.939
28.735.806
28.905.673
18.213.430
18.377.351
18.486.632
18.595.912
21.856.116
22.052.821
22.183.958
22.315.095
30.073.878
30.344.543
30.524.986
30.705.429

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
KATETERISASI RINGAN
KATETERISASI SEDANG
KATETERISASI BERAT
RINGAN
SEDANG
BERAT
229
I-1-01-i
230
I-1-01-ii
231
I-1-01-iii
232
I-1-02-i
233
I-1-02-ii
234
I-1-02-iii
235
I-1-03-i
236
I-1-03-ii
237
I-1-03-iii
238
I-1-04-i
239
I-1-04-ii
240
I-1-04-iii
241
I-1-05-i
242
I-1-05-ii
243
I-1-05-iii
244
I-1-06-i
8.585.407
8.662.676
8.714.188
8.765.701
245
I-1-06-ii
12.957.417
13.074.034
13.151.778
13.229.523
246
I-1-06-iii
16.680.828
16.830.956
16.931.041
17.031.126
247
I-1-07-i
11.290.460
11.392.074
11.459.817
11.527.560
248
I-1-07-ii
13.929.076
14.054.438
14.138.013
14.221.587
249
I-1-07-iii
15.196.532
15.333.301
15.424.480
15.515.659
250
I-1-11-i
2.147.721
2.167.050
2.179.937
2.192.823
251
I-1-11-ii
2.388.051
2.409.543
2.423.872
2.438.200
252
I-1-11-iii
3.177.768
3.206.368
3.225.434
3.244.501

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
RINGAN
SEDANG
BERAT
- 633 No
Kode
INA-CBG
253
I-1-12-i
254
I-1-12-ii
255
I-1-12-iii
256
I-1-13-i
257
I-1-13-ii
258
I-1-13-iii
259
I-1-14-i
260
I-1-14-ii
261
I-1-14-iii
262
I-1-15-i
263
I-1-15-ii
264
I-1-15-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
6.582.399
6.641.640
6.681.135
6.720.629
9.133.385
9.215.586
9.270.386
9.325.186
12.738.916
12.853.567
12.930.000
13.006.434
3.871.999
3.906.847
3.930.079
3.953.311
4.504.834
4.545.377
4.572.406
4.599.435
8.212.011
8.285.919
8.335.191
8.384.463
14.166.001
14.293.495
14.378.491
14.463.487
17.606.316
17.764.773
17.870.411
17.976.048
23.070.345
23.277.978
23.416.400
23.554.822
2.775.857
2.800.840
2.817.495
2.834.150
8.131.198
8.204.379
8.253.166
8.301.953
11.890.807
11.997.824
12.069.169
12.140.514
6.071.143
6.125.784
6.162.211
6.198.637
15.784.973
15.927.038
16.021.747
16.116.457
18.207.579
18.371.447
18.480.692
18.589.938
1.947.064
1.964.588
1.976.270
1.987.953
4.033.076
4.069.374
4.093.573
4.117.771
23.381.324
23.591.756
23.732.044
23.872.332
3.871.999
3.906.847
3.930.079
3.953.311
6.340.096
6.397.156
6.435.197
6.473.238
13.434.092
13.554.999
13.635.603
13.716.208
6.887.744
6.949.733
6.991.060
7.032.386
14.327.898
14.456.850
14.542.817
14.628.784
22.203.039
22.402.866
22.536.084
22.669.303
9.262.463
9.345.825
9.401.399
9.456.974
12.863.571
12.979.343
13.056.525
13.133.706
16.118.644
16.263.712
16.360.424
16.457.136

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

DARAH VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
265
I-1-16-i
266
I-1-16-ii
267
I-1-16-iii
268
I-1-17-i
269
I-1-17-ii
270
I-1-17-iii
271
I-1-20-i
272
I-1-20-ii
273
I-1-20-iii
274
I-1-30-i
275
I-1-30-ii
276
I-1-30-iii
277
I-1-40-i
278
I-1-40-ii
279
I-1-40-iii
280
I-4-10-i
2.693.793
2.718.037
2.734.200
2.750.363
281
I-4-10-ii
4.253.548
4.291.830
4.317.351
4.342.872
- 634 No
Kode
INA-CBG
282
I-4-10-iii
283
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
6.136.114
6.191.339
6.228.156
6.264.972
I-4-11-i
3.194.134
3.222.882
3.242.046
3.261.211
284
I-4-11-ii
3.952.754
3.988.328
4.012.045
4.035.761
285
I-4-11-iii
6.995.436
7.058.395
7.100.367
7.142.340
286
I-4-12-i
2.797.730
2.822.909
2.839.696
2.856.482
287
I-4-12-ii
3.992.352
4.028.283
4.052.238
4.076.192
288
I-4-12-iii
4.843.285
4.886.875
4.915.934
4.944.994
289
I-4-13-i
2.513.130
2.535.749
2.550.827
2.565.906
290
I-4-13-ii
3.651.066
3.683.925
3.705.832
3.727.738
291
I-4-13-iii
7.473.308
7.540.568
7.585.408
7.630.247
292
I-4-14-i
1.562.935
1.577.001
1.586.379
1.595.757
293
I-4-14-ii
1.828.865
1.845.325
1.856.298
1.867.271
294
I-4-14-iii
2.834.132
2.859.640
2.876.644
2.893.649
2.299.479
2.320.175
2.333.972
2.347.768
3.291.819
3.321.445
3.341.196
3.360.947
3.751.881
3.785.648
3.808.159
3.830.671

VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT

295
I-4-15-i
296
I-4-15-ii
297
I-4-15-iii
298
I-4-16-i
1.724.610
1.740.131
1.750.479
1.760.826
299
I-4-16-ii
2.794.998
2.820.153
2.836.923
2.853.693
300
I-4-16-iii
3.521.201
3.552.892
3.574.019
3.595.146
301
I-4-17-i
HIPERTENSI RINGAN
1.543.490
1.557.381
1.566.642
1.575.903
302
I-4-17-ii
HIPERTENSI SEDANG
2.185.735
2.205.407
2.218.521
2.231.636
303
I-4-17-iii
HIPERTENSI BERAT
2.659.051
2.682.983
2.698.937
2.714.891
2.273.117
2.293.575
2.307.214
2.320.853
3.482.263
3.513.604
3.534.497
3.555.391
4.694.649
4.736.901
4.765.069
4.793.237
1.779.012
1.795.023
1.805.697
1.816.371
2.913.966
2.940.192
2.957.676
2.975.159
3.473.421
3.504.682
3.525.522
3.546.363

RINGAN
SEDANG
KONGENITAL BERAT
RINGAN
SEDANG
BERAT
304
I-4-18-i
305
I-4-18-ii
306
I-4-18-iii
307
I-4-19-i
308
I-4-19-ii
309
I-4-19-iii
310
I-4-20-i
2.159.083
2.178.515
2.191.469
2.204.424
311
I-4-20-ii
2.487.425
2.509.812
2.524.736
2.539.661
312
I-4-20-iii
3.301.227
3.330.938
3.350.745
3.370.553
313
I-4-21-i
2.871.231
2.897.072
2.914.300
2.931.527
314
I-4-21-ii
3.581.675
3.613.910
3.635.400
3.656.890
- 635 No
Kode
INA-CBG
315
I-4-21-iii
316
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.886.164
4.930.139
4.959.456
4.988.773
I-4-22-i
1.868.327
1.885.142
1.896.352
1.907.562
317
I-4-22-ii
2.152.872
2.172.248
2.185.165
2.198.082
318
I-4-22-iii
3.140.982
3.169.250
3.188.096
3.206.942
1.415.363
1.428.101
1.436.594
1.445.086
1.737.740
1.753.379
1.763.806
1.774.232
3.395.385
3.425.943
3.446.316
3.466.688
1.688.119
1.703.312
1.713.441
1.723.570
4.214.767
4.252.700
4.277.989
4.303.277
5.328.812
5.376.771
5.408.744
5.440.717
13.863.818
13.988.592
14.071.775
14.154.958
15.100.797
15.236.704
15.327.309
15.417.913
24.823.796
25.047.210
25.196.153
25.345.096
6.952.387
7.014.959
7.056.673
7.098.388
7.447.859
7.514.890
7.559.577
7.604.264
11.005.814
11.104.866
11.170.901
11.236.936
2.712.922
2.737.338
2.753.616
2.769.893
6.552.693
6.611.667
6.650.983
6.690.299
11.602.348
11.706.769
11.776.383
11.845.997
2.344.833
2.365.936
2.380.005
2.394.074
3.410.374
3.441.067
3.461.530
3.481.992
5.128.149
5.174.303
5.205.072
5.235.840
1.581.250
1.595.481
1.604.969
1.614.456
7.743.998
7.813.694
7.860.158
7.906.622
23.355.559
23.565.759
23.705.892
23.846.026

RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
319
I-4-23-i
320
I-4-23-ii
321
I-4-23-iii
322
I-4-24-i
323
I-4-24-ii
324
I-4-24-iii
325
J-1-01-i
326
J-1-01-ii
327
J-1-01-iii
328
J-1-02-i
329
J-1-02-ii
330
J-1-02-iii
331
J-1-10-i
332
J-1-10-ii
333
J-1-10-iii
334
J-1-20-i
335
J-1-20-ii
336
J-1-20-iii
337
J-1-30-i
338
J-1-30-ii
339
J-1-30-iii
340
J-4-10-i
1.824.974
1.841.399
1.852.348
1.863.298
341
J-4-10-ii
2.609.493
2.632.979
2.648.636
2.664.293
342
J-4-10-iii
3.947.774
3.983.304
4.006.990
4.030.677
343
J-4-11-i
1.151.326
1.161.688
1.168.596
1.175.504
344
J-4-11-ii
1.602.620
1.617.044
1.626.659
1.636.275
345
J-4-11-iii
2.296.595
2.317.265
2.331.044
2.344.824
- 636 No
Kode
INA-CBG
346
J-4-12-i
347
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
EMBOLI PARU RINGAN
1.760.677
1.776.523
1.787.087
1.797.651
J-4-12-ii
EMBOLI PARU SEDANG
2.280.016
2.300.537
2.314.217
2.327.897
348
J-4-12-iii
EMBOLI PARU BERAT
3.044.731
3.072.134
3.090.402
3.108.671
349
J-4-13-i
2.712.111
2.736.520
2.752.793
2.769.065
350
J-4-13-ii
3.986.803
4.022.685
4.046.605
4.070.526
351
J-4-13-iii
6.481.945
6.540.283
6.579.175
6.618.066
352
J-4-14-i
TUMOR PARU RINGAN
1.848.218
1.864.852
1.875.941
1.887.031
353
J-4-14-ii
TUMOR PARU SEDANG
3.096.018
3.123.882
3.142.458
3.161.034
354
J-4-14-iii
TUMOR PARU BERAT
3.681.008
3.714.137
3.736.223
3.758.309
1.724.610
1.740.131
1.750.479
1.760.826
3.120.934
3.149.022
3.167.748
3.186.473
3.899.544
3.934.640
3.958.037
3.981.434
1.437.175
1.450.109
1.458.732
1.467.355
2.012.044
2.030.153
2.042.225
2.054.297
3.629.516
3.662.182
3.683.959
3.705.736

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
355
J-4-15-i
356
J-4-15-ii
357
J-4-15-iii
358
J-4-16-i
359
J-4-16-ii
360
J-4-16-iii
361
J-4-17-i
1.794.809
1.810.962
1.821.731
1.832.500
362
J-4-17-ii
2.425.095
2.446.921
2.461.472
2.476.022
363
J-4-17-iii
3.170.595
3.199.131
3.218.154
3.237.178
364
J-4-18-i
1.149.740
1.160.087
1.166.986
1.173.884
365
J-4-18-ii
2.248.476
2.268.712
2.282.203
2.295.694
366
J-4-18-iii
2.332.167
2.353.156
2.367.149
2.381.142
367
J-4-19-i
2.012.044
2.030.153
2.042.225
2.054.297
368
J-4-19-ii
2.299.479
2.320.175
2.333.972
2.347.768
369
J-4-19-iii
3.602.404
3.634.826
3.656.440
3.678.054
370
J-4-20-i
2.012.044
2.030.153
2.042.225
2.054.297
371
J-4-20-ii
2.454.322
2.476.411
2.491.137
2.505.863
372
J-4-20-iii
5.545.884
5.595.797
5.629.072
5.662.347
1.149.740
1.160.087
1.166.986
1.173.884
2.836.618
2.862.147
2.879.167
2.896.187
4.045.945
4.082.358
4.106.634
4.130.909
3.097.599
3.125.478
3.144.063
3.162.649
4.322.903
4.361.809
4.387.747
4.413.684
5.062.864
5.108.430
5.138.807
5.169.184
373
J-4-21-i
374
J-4-21-ii
375
J-4-21-iii
376
K-1-10-i
377
K-1-10-ii
378
K-1-10-iii

USUS BESAR (RINGAN)
USUS BESAR (SEDANG)
USUS BESAR (BERAT)
- 637 No
Kode
INA-CBG
Deskripsi (INA-CBG)
379
K-1-11-i
380
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.663.459
2.687.430
2.703.411
2.719.392
K-1-11-ii
3.496.800
3.528.271
3.549.252
3.570.233
381
K-1-11-iii
8.874.191
8.954.058
9.007.304
9.060.549
382
K-1-12-i
1.432.737
1.445.632
1.454.228
1.462.825
383
K-1-12-ii
1.867.300
1.884.105
1.895.309
1.906.513
384
K-1-12-iii
3.714.452
3.747.882
3.770.168
3.792.455
385
K-1-13-i
2.115.611
2.134.651
2.147.345
2.160.039
386
K-1-13-ii
3.695.364
3.728.623
3.750.795
3.772.967
387
K-1-13-iii
3.952.059
3.987.628
4.011.340
4.035.052
388
K-1-14-i
3.418.952
3.449.723
3.470.237
3.490.750
389
K-1-14-ii
4.015.947
4.052.090
4.076.186
4.100.282
390
K-1-14-iii
9.888.426
9.977.421
10.036.752
10.096.083
391
K-1-20-i
5.102.900
5.148.826
5.179.444
5.210.061
392
K-1-20-ii
7.122.303
7.186.404
7.229.138
7.271.872
393
K-1-20-iii
15.213.576
15.350.498
15.441.780
15.533.061
394
K-1-30-i
3.358.983
3.389.214
3.409.368
3.429.522
395
K-1-30-ii
6.195.199
6.250.955
6.288.127
6.325.298
396
K-1-30-iii
9.648.227
9.735.061
9.792.951
9.850.840
397
K-1-40-i
4.386.855
4.426.337
4.452.658
4.478.979
398
K-1-40-ii
4.827.298
4.870.744
4.899.708
4.928.672
399
K-1-40-iii
8.005.609
8.077.660
8.125.693
8.173.727
400
K-1-50-i
3.346.112
3.376.227
3.396.304
3.416.380
401
K-1-50-ii
4.333.373
4.372.373
4.398.373
4.424.374
402
K-1-50-iii
PROSEDUR ANAL BERAT
6.152.237
6.207.607
6.244.521
6.281.434
403
K-4-10-i
1.949.569
1.967.115
1.978.812
1.990.509
404
K-4-10-ii
2.332.773
2.353.768
2.367.765
2.381.762
405
K-4-10-iii
9.659.984
9.746.924
9.804.884
9.862.844
406
K-4-11-i
1.149.740
1.160.087
1.166.986
1.173.884
407
K-4-11-ii
1.724.610
1.740.131
1.750.479
1.760.826
408
K-4-11-iii
3.134.237
3.162.445
3.181.250
3.200.056
409
K-4-12-i
1.149.740
1.160.087
1.166.986
1.173.884
410
K-4-12-ii
1.717.693
1.733.152
1.743.459
1.753.765
411
K-4-12-iii
4.122.341
4.159.442
4.184.176
4.208.911


RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
- 638 No
Kode
INA-CBG
412
K-4-13-i
413
K-4-13-ii
414
K-4-13-iii
415
K-4-14-i
416
K-4-14-ii
417
K-4-14-iii
418
K-4-15-i
419
K-4-15-ii
420
K-4-15-iii
421
K-4-16-i
422
K-4-16-ii
423
K-4-16-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.724.610
1.740.131
1.750.479
1.760.826
2.233.794
2.253.898
2.267.301
2.280.704
3.653.509
3.686.391
3.708.312
3.730.233
1.437.175
1.450.109
1.458.732
1.467.355
1.945.066
1.962.571
1.974.242
1.985.912
2.942.098
2.968.576
2.986.229
3.003.882
1.437.175
1.450.109
1.458.732
1.467.355
2.702.280
2.726.601
2.742.814
2.759.028
3.844.858
3.879.462
3.902.531
3.925.600
1.437.175
1.450.109
1.458.732
1.467.355
1.724.610
1.740.131
1.750.479
1.760.826
2.105.110
2.124.056
2.136.687
2.149.317
1.149.740
1.160.087
1.166.986
1.173.884
1.677.492
1.692.589
1.702.654
1.712.719
2.232.570
2.252.663
2.266.059
2.279.454
1.149.740
1.160.087
1.166.986
1.173.884
1.784.873
1.800.937
1.811.646
1.822.355
2.111.496
2.130.499
2.143.168
2.155.837
11.765.575
11.871.465
11.942.059
12.012.652
12.239.441
12.349.596
12.423.033
12.496.470
24.687.324
24.909.510
25.057.634
25.205.758
5.336.518
5.384.547
5.416.566
5.448.585
7.729.964
7.799.534
7.845.914
7.892.293
8.152.700
8.226.075
8.274.991
8.323.907
2.801.150
2.826.360
2.843.167
2.859.974
6.304.548
6.361.289
6.399.117
6.436.944
10.684.543
10.780.704
10.844.812
10.908.919

(RINGAN)
(SEDANG)
RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
424
K-4-17-i
425
K-4-17-ii
426
K-4-17-iii
427
K-4-18-i
428
K-4-18-ii
429
K-4-18-iii
430
L-1-20-i
431
L-1-20-ii
432
L-1-20-iii
433
L-1-30-i
434
L-1-30-ii
435
L-1-30-iii
436
L-1-40-i
437
L-1-40-ii
438
L-1-40-iii
439
L-1-50-i
4.646.399
4.688.217
4.716.095
4.743.973
440
L-1-50-ii
8.363.518
8.438.790
8.488.971
8.539.152
441
L-1-50-iii
10.112.677
10.203.691
10.264.367
10.325.043
442
L-4-10-i
1.724.610
1.740.131
1.750.479
1.760.826
- 639 No
Kode
INA-CBG
443
L-4-10-ii
444
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.012.044
2.030.153
2.042.225
2.054.297
L-4-10-iii
4.070.194
4.106.826
4.131.247
4.155.668
445
L-4-11-i
1.631.167
1.645.847
1.655.634
1.665.421
446
L-4-11-ii
2.234.670
2.254.782
2.268.190
2.281.598
447
L-4-11-iii
6.060.144
6.114.686
6.151.047
6.187.407
448
L-4-12-i
1.724.610
1.740.131
1.750.479
1.760.826
449
L-4-12-ii
2.530.402
2.553.176
2.568.358
2.583.541
450
L-4-12-iii
4.243.185
4.281.374
4.306.833
4.332.292
451
L-4-13-i
1.082.485
1.092.228
1.098.723
1.105.218
452
L-4-13-ii
1.248.169
1.259.403
1.266.892
1.274.381
453
L-4-13-iii
1.872.352
1.889.203
1.900.437
1.911.671
454
L-4-14-i
1.149.740
1.160.087
1.166.986
1.173.884
455
L-4-14-ii
1.724.610
1.740.131
1.750.479
1.760.826
456
L-4-14-iii
2.696.458
2.720.726
2.736.905
2.753.084
457
M-1-01-i
5.605.429
5.655.878
5.689.510
5.723.143
458
M-1-01-ii
6.256.565
6.312.874
6.350.414
6.387.953
459
M-1-01-iii
8.788.779
8.867.878
8.920.611
8.973.344
460
M-1-02-i
3.970.073
4.005.804
4.029.624
4.053.445
461
M-1-02-ii
6.518.106
6.576.769
6.615.877
6.654.986
462
M-1-02-iii
11.803.990
11.910.226
11.981.050
12.051.874
10.067.198
10.157.803
10.218.206
10.278.609
11.781.566
11.887.600
11.958.289
12.028.978
12.003.197
12.111.226
12.183.245
12.255.265
2.618.938
2.642.509
2.658.222
2.673.936
3.357.452
3.387.669
3.407.814
3.427.958
4.201.218
4.239.029
4.264.236
4.289.444
4.079.803
4.116.521
4.141.000
4.165.479
4.715.159
4.757.595
4.785.886
4.814.177
8.031.200
8.103.481
8.151.668
8.199.855
4.503.531
4.544.063
4.571.084
4.598.106
6.033.325
6.087.625
6.123.825
6.160.025
12.290.455
12.401.069
12.474.812
12.548.554
463
M-1-03-i
464
M-1-03-ii
465
M-1-03-iii
466
M-1-04-i
467
M-1-04-ii
468
M-1-04-iii
469
M-1-05-i
470
M-1-05-ii
471
M-1-05-iii
472
M-1-07-i
473
M-1-07-ii
474
M-1-07-iii


- 640 No
Kode
INA-CBG
475
M-1-10-i
476
M-1-10-ii
477
M-1-10-iii
478
M-1-20-i
479
M-1-20-ii
480
M-1-20-iii
481
M-1-30-i
482
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.814.621
2.839.952
2.856.840
2.873.728
10.455.040
10.549.135
10.611.866
10.674.596
12.788.507
12.903.603
12.980.334
13.057.065
2.784.387
2.809.446
2.826.153
2.842.859
3.974.463
4.010.233
4.034.079
4.057.926
7.725.489
7.795.018
7.841.371
7.887.724
1.665.480
1.680.469
1.690.462
1.700.455
M-1-30-ii
3.441.305
3.472.276
3.492.924
3.513.572
483
M-1-30-iii
PROSEDUR KAKI BERAT
5.133.701
5.179.904
5.210.706
5.241.509
484
M-1-40-i
2.187.689
2.207.378
2.220.505
2.233.631
485
M-1-40-ii
4.026.879
4.063.121
4.087.282
4.111.444
486
M-1-40-iii
6.504.959
6.563.503
6.602.533
6.641.563
487
M-1-50-i
2.897.319
2.923.394
2.940.778
2.958.162
488
M-1-50-ii
5.832.370
5.884.862
5.919.856
5.954.850
489
M-1-50-iii
7.434.238
7.501.147
7.545.752
7.590.357
490
M-1-60-i
2.186.561
2.206.240
2.219.360
2.232.479
491
M-1-60-ii
4.377.510
4.416.908
4.443.173
4.469.438
492
M-1-60-iii
7.618.416
7.686.981
7.732.692
7.778.402
493
M-1-70-i
2.253.164
2.273.442
2.286.961
2.300.480
494
M-1-70-ii
4.597.570
4.638.948
4.666.534
4.694.119
495
M-1-70-iii
7.411.838
7.478.545
7.523.016
7.567.487
496
M-1-80-i
2.360.072
2.381.313
2.395.473
2.409.634
497
M-1-80-ii
3.567.947
3.600.058
3.621.466
3.642.874
498
M-1-80-iii
8.214.338
8.288.267
8.337.553
8.386.839
499
M-4-10-i
1.149.740
1.160.087
1.166.986
1.173.884
500
M-4-10-ii
1.754.214
1.770.002
1.780.527
1.791.053
501
M-4-10-iii
FRAKTUR FEMUR BERAT
3.724.981
3.758.506
3.780.855
3.803.205
502
M-4-11-i
1.521.622
1.535.317
1.544.446
1.553.576
503
M-4-11-ii
3.490.827
3.522.245
3.543.190
3.564.135
504
M-4-11-iii
6.196.137
6.251.902
6.289.079
6.326.256
505
M-4-12-i
1.149.740
1.160.087
1.166.986
1.173.884

TULANG WAJAH RINGAN
TULANG WAJAH SEDANG
TULANG WAJAH BERAT

RINGAN
SEDANG
BERAT

SELAIN KAKI (BERAT)

PANGGUL RINGAN
PANGGUL SEDANG
PANGGUL BERAT
PELVIS RINGAN
- 641 No
Kode
INA-CBG
506
M-4-12-ii
507
M-4-12-iii
508
M-4-13-i
509
M-4-13-ii
510
M-4-13-iii
511
M-4-14-i
512
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.091.950
2.110.778
2.123.329
2.135.881
4.189.628
4.227.335
4.252.473
4.277.611
2.122.521
2.141.624
2.154.359
2.167.094
2.874.349
2.900.218
2.917.464
2.934.711
6.313.968
6.370.794
6.408.678
6.446.561
2.299.479
2.320.175
2.333.972
2.347.768
M-4-14-ii
2.985.341
3.012.209
3.030.121
3.048.033
513
M-4-14-iii
OSTEOMIELITIS BERAT
4.471.719
4.511.964
4.538.794
4.565.625
514
M-4-15-i
1.434.629
1.447.541
1.456.149
1.464.756
515
M-4-15-ii
1.912.960
1.930.176
1.941.654
1.953.132
516
M-4-15-iii
4.886.394
4.930.371
4.959.690
4.989.008
517
M-4-16-i
1.437.175
1.450.109
1.458.732
1.467.355
518
M-4-16-ii
2.299.479
2.320.175
2.333.972
2.347.768
519
M-4-16-iii
4.275.717
4.314.199
4.339.853
4.365.508
520
M-4-17-i
1.437.175
1.450.109
1.458.732
1.467.355
521
M-4-17-ii
2.012.044
2.030.153
2.042.225
2.054.297
522
M-4-17-iii
2.809.927
2.835.216
2.852.076
2.868.935
523
M-4-18-i
1.684.592
1.699.753
1.709.861
1.719.968
524
M-4-18-ii
2.299.479
2.320.175
2.333.972
2.347.768
525
M-4-18-iii
2.856.969
2.882.682
2.899.824
2.916.966
526
M-4-19-i
1.252.517
1.263.789
1.271.305
1.278.820
527
M-4-19-ii
2.109.639
2.128.626
2.141.284
2.153.942
528
M-4-19-iii
4.120.282
4.157.364
4.182.086
4.206.808
529
M-4-20-i
1.149.740
1.160.087
1.166.986
1.173.884
530
M-4-20-ii
1.724.610
1.740.131
1.750.479
1.760.826
531
M-4-20-iii
1.911.274
1.928.475
1.939.943
1.951.411
532
M-4-21-i
1.149.740
1.160.087
1.166.986
1.173.884
533
M-4-21-ii
1.500.699
1.514.206
1.523.210
1.532.214
534
M-4-21-iii
3.658.072
3.690.994
3.712.943
3.734.891
535
N-1-01-i
3.110.885
3.138.882
3.157.548
3.176.213
536
N-1-01-ii
4.207.401
4.245.268
4.270.512
4.295.756

PELVIS SEDANG
PELVIS BERAT

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
RINGAN
SEDANG
BERAT
ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
- 642 No
Kode
INA-CBG
537
N-1-01-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
8.920.942
9.001.230
9.054.756
9.108.282
4.291.705
4.330.331
4.356.081
4.381.831
5.804.435
5.856.675
5.891.501
5.926.328
12.307.128
12.417.892
12.491.735
12.565.578
2.323.199
2.344.108
2.358.047
2.371.987
5.404.759
5.453.402
5.485.831
5.518.259
9.850.510
9.939.165
9.998.268
10.057.371
538
N-1-11-i
539
N-1-11-ii
540
N-1-11-iii
541
N-1-12-i
542
N-1-12-ii
543
N-1-12-iii
544
N-1-20-i
3.145.429
3.173.737
3.192.610
3.211.483
545
N-1-20-ii
6.236.267
6.292.393
6.329.811
6.367.228
546
N-1-20-iii
7.133.724
7.197.927
7.240.730
7.283.532
3.742.043
3.775.721
3.798.173
3.820.625
5.686.500
5.737.679
5.771.798
5.805.917
6.546.100
6.605.014
6.644.291
6.683.568
3.371.947
3.402.294
3.422.526
3.442.757
4.570.794
4.611.931
4.639.356
4.666.781
5.315.965
5.363.809
5.395.705
5.427.601
1.437.175
1.450.109
1.458.732
1.467.355
1.924.417
1.941.737
1.953.283
1.964.830
4.212.202
4.250.112
4.275.385
4.300.659


URIN BAWAH RINGAN
URIN BAWAH SEDANG
URIN BAWAH BERAT
RINGAN
SEDANG
BERAT
GINJAL RINGAN
GINJAL SEDANG
GINJAL BERAT
547
N-1-30-i
548
N-1-30-ii
549
N-1-30-iii
550
N-1-40-i
551
N-1-40-ii
552
N-1-40-iii
553
N-4-10-i
554
N-4-10-ii
555
N-4-10-iii
556
N-4-11-i
1.100.593
1.110.498
1.117.102
1.123.705
557
N-4-11-ii
1.859.975
1.876.715
1.887.875
1.899.035
558
N-4-11-iii
2.155.762
2.175.164
2.188.098
2.201.033
559
N-4-12-i
1.149.740
1.160.087
1.166.986
1.173.884
560
N-4-12-ii
1.724.610
1.740.131
1.750.479
1.760.826
561
N-4-12-iii
2.863.419
2.889.189
2.906.370
2.923.550
562
N-4-13-i
BATU URIN RINGAN
1.516.860
1.530.512
1.539.613
1.548.714
563
N-4-13-ii
BATU URIN SEDANG
1.828.763
1.845.222
1.856.194
1.867.167
564
N-4-13-iii
BATU URIN BERAT
4.503.741
4.544.275
4.571.297
4.598.320
565
N-4-14-i
995.888
1.004.851
1.010.826
1.016.801
566
N-4-14-ii
1.533.542
1.547.344
1.556.545
1.565.746

(RINGAN)
(SEDANG)
- 643 No
Kode
INA-CBG
567
N-4-14-iii
568
N-4-15-i
569
N-4-15-ii
570
N-4-15-iii
571
N-4-16-i
572
N-4-16-ii
573
N-4-16-iii
574
O-6-10-i
575
O-6-10-ii
576
O-6-10-iii
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
584
O-6-13-ii
585
O-6-13-iii
586
P-8-01-i
587
P-8-01-ii
588
P-8-01-iii
589
P-8-02-i
590
P-8-02-ii
591
P-8-02-iii
592
P-8-03-i
593
P-8-03-ii
594
P-8-03-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.486.916
2.509.298
2.524.220
2.539.141
1.477.477
1.490.774
1.499.639
1.508.504
2.027.558
2.045.806
2.057.971
2.070.137
2.313.810
2.334.634
2.348.517
2.362.400
1.917.561
1.934.819
1.946.324
1.957.830
2.299.479
2.320.175
2.333.972
2.347.768
4.835.463
4.878.982
4.907.995
4.937.008
2.972.942
2.999.699
3.017.536
3.035.374
3.300.419
3.330.123
3.349.925
3.369.728
4.052.172
4.088.641
4.112.954
4.137.267
1.923.710
1.941.023
1.952.566
1.964.108
2.467.944
2.490.156
2.504.964
2.519.771
4.182.400
4.220.042
4.245.136
4.270.230
1.288.597
1.300.194
1.307.926
1.315.657
1.547.601
1.561.530
1.570.815
1.580.101
1.944.339
1.961.839
1.973.505
1.985.171
1.485.117
1.498.483
1.507.394
1.516.305
1.806.069
1.822.324
1.833.160
1.843.997
2.246.086
2.266.301
2.279.777
2.293.254
28.888.173
29.148.167
29.321.496
29.494.825
35.744.596
36.066.297
36.280.765
36.495.232
41.954.135
42.331.723
42.583.447
42.835.172
35.000.277
35.315.279
35.525.281
35.735.283
40.148.920
40.510.260
40.751.154
40.992.047
45.873.012
46.285.869
46.561.107
46.836.345
1.936.000
1.953.424
1.965.040
1.976.656
2.710.399
2.734.793
2.751.055
2.767.318
4.269.494
4.307.919
4.333.536
4.359.153

(BERAT)
SALURAN URIN RINGAN
SALURAN URIN SEDANG
SALURAN URIN BERAT
RINGAN
SEDANG
BERAT
&KURET RINGAN
KURET SEDANG
KURET BERAT

- 644 No
Kode
INA-CBG
595
P-8-04-i
596
P-8-04-ii
597
P-8-04-iii
598
P-8-05-i
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii
603
P-8-06-iii
604
P-8-07-i
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
614
P-8-11-ii
615
P-8-11-iii
616
P-8-12-i
617
P-8-12-ii
618
P-8-12-iii
619
P-8-13-i
620
P-8-13-ii
621
P-8-13-iii
622
P-8-14-i
Deskripsi (INA-CBG)
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
RINGAN
SEDANG
BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
17.289.836
17.445.445
17.549.184
17.652.923
22.438.479
22.640.426
22.775.057
22.909.687
32.171.132
32.460.672
32.653.699
32.846.725
9.401.652
9.486.267
9.542.677
9.599.087
13.325.575
13.445.505
13.525.458
13.605.412
19.633.445
19.810.146
19.927.947
20.045.748
1.548.800
1.562.739
1.572.032
1.581.324
3.897.186
3.932.260
3.955.644
3.979.027
7.249.210
7.314.453
7.357.948
7.401.443
2.710.399
2.734.793
2.751.055
2.767.318
7.599.308
7.667.701
7.713.297
7.758.893
10.067.198
10.157.803
10.218.206
10.278.609
1.964.177
1.981.855
1.993.640
2.005.425
2.788.426
2.813.522
2.830.252
2.846.983
3.936.401
3.971.828
3.995.447
4.019.065
1.218.573
1.229.540
1.236.852
1.244.163
1.765.281
1.781.168
1.791.760
1.802.352
3.465.766
3.496.958
3.517.753
3.538.547
1.616.502
1.631.050
1.640.749
1.650.448
7.306.677
7.372.437
7.416.277
7.460.117
7.459.753
7.526.891
7.571.649
7.616.408
1.619.137
1.633.709
1.643.424
1.653.139
2.517.477
2.540.134
2.555.239
2.570.344
2.970.090
2.996.821
3.014.642
3.032.462
836.857
844.389
849.410
854.431
1.548.598
1.562.535
1.571.827
1.581.118
2.316.094
2.336.939
2.350.835
2.364.732
1.529.025
1.542.787
1.551.961
1.561.135
- 645 No
Kode
INA-CBG
623
P-8-14-ii
624
P-8-14-iii
625
P-8-15-i
626
P-8-15-ii
627
P-8-15-iii
628
P-8-16-i
629
P-8-16-ii
630
P-8-16-iii
631
P-8-17-i
632
P-8-17-ii
633
P-8-17-iii
634
S-4-10-i
635
S-4-10-ii
636
S-4-10-iii
637
S-4-11-i
638
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.121.837
3.149.933
3.168.664
3.187.395
3.424.643
3.455.465
3.476.013
3.496.561
1.149.875
1.160.224
1.167.123
1.174.022
2.298.297
2.318.982
2.332.772
2.346.561
2.699.706
2.724.003
2.740.201
2.756.400
1.040.908
1.050.277
1.056.522
1.062.767
1.476.573
1.489.862
1.498.722
1.507.581
1.916.664
1.933.914
1.945.414
1.956.914
686.997
693.180
697.302
701.424
2.281.972
2.302.510
2.316.202
2.329.894
4.606.016
4.647.470
4.675.106
4.702.742
1.149.740
1.160.087
1.166.986
1.173.884
1.437.175
1.450.109
1.458.732
1.467.355
1.868.080
1.884.893
1.896.101
1.907.310
718.587
725.055
729.366
733.678
S-4-11-ii
1.093.703
1.103.547
1.110.109
1.116.671
639
S-4-11-iii
1.769.421
1.785.346
1.795.962
1.806.579
640
S-4-12-i
862.305
870.065
875.239
880.413
641
S-4-12-ii
1.149.740
1.160.087
1.166.986
1.173.884
642
S-4-12-iii
2.245.533
2.265.742
2.279.216
2.292.689
643
S-4-13-i
1.149.740
1.160.087
1.166.986
1.173.884
644
S-4-13-ii
2.032.482
2.050.774
2.062.969
2.075.164
645
S-4-13-iii
4.138.392
4.175.637
4.200.467
4.225.298
646
S-4-14-i
700.515
706.820
711.023
715.226
647
S-4-14-ii
1.488.129
1.501.523
1.510.451
1.519.380
648
S-4-14-iii
2.822.023
2.847.422
2.864.354
2.881.286
649
S-4-15-i
529.806
534.574
537.753
540.932
650
S-4-15-ii
999.925
1.008.924
1.014.924
1.020.923
651
S-4-15-iii
1.295.135
1.306.791
1.314.562
1.322.333
652
S-4-16-i
LUKA BAKAR RINGAN
2.012.044
2.030.153
2.042.225
2.054.297
653
S-4-16-ii
LUKA BAKAR SEDANG
2.841.662
2.867.237
2.884.287
2.901.337
654
S-4-16-iii
LUKA BAKAR BERAT
5.074.229
5.119.897
5.150.342
5.180.788

ASPIRASI RINGAN
ASPIRASI SEDANG
ASPIRASI BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT

PASIEN RINGAN
PASIEN SEDANG
PASIEN BERAT
- 646 No
Kode
INA-CBG
655
S-4-17-i
656
S-4-17-ii
657
S-4-17-iii
658
T-1-10-i
659
T-1-10-ii
660
T-1-10-iii
661
T-4-10-i
662
T-4-10-ii
663
T-4-10-iii
664
T-4-11-i
665
T-4-11-ii
666
T-4-11-iii
667
T-4-12-i
668
T-4-12-ii
669
T-4-12-iii
670
U-1-10-i
671
U-1-10-ii
672
U-1-10-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.072.862
1.082.517
1.088.954
1.095.392
1.437.175
1.450.109
1.458.732
1.467.355
2.343.597
2.364.689
2.378.751
2.392.812
1.107.489
1.117.457
1.124.102
1.130.746
1.487.283
1.500.668
1.509.592
1.518.516
2.705.852
2.730.205
2.746.440
2.762.675
484.447
488.807
491.714
494.621
923.249
931.559
937.098
942.638
1.342.154
1.354.233
1.362.286
1.370.339
479.091
483.403
486.277
489.152
753.952
760.738
765.262
769.785
1.214.395
1.225.325
1.232.611
1.239.898
1.006.022
1.015.076
1.021.113
1.027.149
1.520.547
1.534.232
1.543.355
1.552.479
2.365.425
2.386.714
2.400.906
2.415.099
1.070.819
1.080.456
1.086.881
1.093.306
2.185.071
2.204.737
2.217.847
2.230.957
9.435.578
9.520.498
9.577.111
9.633.725
4.646.399
4.688.217
4.716.095
4.743.973
6.195.199
6.250.955
6.288.127
6.325.298
10.408.485
10.502.162
10.564.613
10.627.063

DOKTER RINGAN
DOKTER SEDANG
DOKTER BERAT

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
673
U-1-11-i
674
U-1-11-ii
675
U-1-11-iii
676
U-1-12-i
2.839.465
2.865.020
2.882.057
2.899.093
677
U-1-12-ii
6.969.598
7.032.325
7.074.142
7.115.960
678
U-1-12-iii
9.050.156
9.131.607
9.185.908
9.240.209
679
U-1-13-i
3.097.599
3.125.478
3.144.063
3.162.649
680
U-1-13-ii
3.494.932
3.526.387
3.547.356
3.568.326
681
U-1-13-iii
6.739.215
6.799.868
6.840.304
6.880.739
1.709.158
1.724.540
1.734.795
1.745.050
2.097.480
2.116.358
2.128.943
2.141.528
2.485.573
2.507.944
2.522.857
2.537.770
1.305.010
1.316.755
1.324.585
1.332.415
682
U-1-14-i
683
U-1-14-ii
684
U-1-14-iii
685
U-1-15-i

- 647 No
Kode
INA-CBG
686
U-1-15-ii
687
U-1-15-iii
688
U-1-20-i
689
U-1-20-ii
690
U-1-20-iii
691
U-1-30-i
692
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.854.328
1.871.017
1.882.143
1.893.269
3.654.027
3.686.913
3.708.838
3.730.762
2.596.532
2.619.901
2.635.480
2.651.059
4.621.827
4.663.424
4.691.154
4.718.885
11.402.216
11.504.836
11.573.249
11.641.663
2.227.372
2.247.418
2.260.782
2.274.146
U-1-30-ii
3.006.952
3.034.014
3.052.056
3.070.098
693
U-1-30-iii
5.894.490
5.947.541
5.982.907
6.018.274
694
U-4-10-i
2.073.311
2.091.971
2.104.411
2.116.851
695
U-4-10-ii
5.197.355
5.244.131
5.275.316
5.306.500
696
U-4-10-iii
7.581.810
7.650.046
7.695.537
7.741.028
697
U-4-11-i
1.149.740
1.160.087
1.166.986
1.173.884
698
U-4-11-ii
1.724.610
1.740.131
1.750.479
1.760.826
699
U-4-11-iii
2.385.128
2.406.594
2.420.905
2.435.216
700
U-4-12-i
1.149.740
1.160.087
1.166.986
1.173.884
701
U-4-12-ii
1.340.332
1.352.395
1.360.437
1.368.479
702
U-4-12-iii
2.131.066
2.150.246
2.163.032
2.175.819
703
U-4-13-i
1.129.535
1.139.700
1.146.478
1.153.255
704
U-4-13-ii
1.313.150
1.324.968
1.332.847
1.340.726
705
U-4-13-iii
1.490.986
1.504.404
1.513.350
1.522.296
706
U-4-14-i
1.437.175
1.450.109
1.458.732
1.467.355
707
U-4-14-ii
1.724.610
1.740.131
1.750.479
1.760.826
708
U-4-14-iii
2.889.020
2.915.021
2.932.355
2.949.690
1.149.740
1.160.087
1.166.986
1.173.884
1.437.175
1.450.109
1.458.732
1.467.355
2.012.434
2.030.546
2.042.621
2.054.696
3.361.070
3.391.320
3.411.486
3.431.653
3.871.999
3.906.847
3.930.079
3.953.311
7.356.798
7.423.010
7.467.150
7.511.291


DAN TELINGA RINGAN
DAN TELINGA SEDANG
DAN TELINGA BERAT


KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT
709
U-4-15-i
710
U-4-15-ii
711
U-4-15-iii
712
V-1-10-i
713
V-1-10-ii
714
V-1-10-iii
715
V-1-11-i
3.871.999
3.906.847
3.930.079
3.953.311
716
V-1-11-ii
4.321.216
4.360.107
4.386.034
4.411.962
717
V-1-11-iii
6.399.059
6.456.651
6.495.045
6.533.440
718
V-1-12-i

2.091.191
2.110.012
2.122.559
2.135.106
- 648 No
Kode
INA-CBG
719
V-1-12-ii
720
V-1-12-iii
721
V-1-13-i
722
V-1-13-ii
723
V-1-13-iii
724
V-1-14-i
725
V-1-14-ii
726
V-1-14-iii
727
V-1-15-i
728
V-1-15-ii
729
V-1-15-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
7.991.837
8.063.763
8.111.714
8.159.665
9.331.198
9.415.178
9.471.165
9.527.153
4.120.438
4.157.522
4.182.244
4.206.967
7.830.014
7.900.485
7.947.465
7.994.445
10.686.718
10.782.898
10.847.018
10.911.139
3.820.951
3.855.339
3.878.265
3.901.191
5.557.245
5.607.260
5.640.604
5.673.947
7.554.266
7.622.255
7.667.580
7.712.906
1.801.365
1.817.578
1.828.386
1.839.194
3.431.251
3.462.132
3.482.719
3.503.307
6.032.073
6.086.362
6.122.554
6.158.746
2.900.653
2.926.759
2.944.163
2.961.567
3.746.540
3.780.259
3.802.738
3.825.217
7.160.295
7.224.738
7.267.700
7.310.662
1.475.091
1.488.367
1.497.217
1.506.068
2.155.343
2.174.741
2.187.673
2.200.605
3.556.174
3.588.179
3.609.516
3.630.853
4.337.489
4.376.527
4.402.552
4.428.576
5.224.300
5.271.319
5.302.664
5.334.010
11.539.441
11.643.296
11.712.532
11.781.769

NON KOMPLEK (BERAT)

RINGAN
SEDANG
BERAT
730
V-4-10-i
731
V-4-10-ii
732
V-4-10-iii
733
V-4-11-i
734
V-4-11-ii
735
V-4-11-iii
736
W-1-01-i
737
W-1-01-ii
738
W-1-01-iii
739
W-1-10-i
1.207.986
1.218.857
1.226.105
1.233.353
740
W-1-10-ii
2.254.299
2.274.588
2.288.114
2.301.639
741
W-1-10-iii
3.687.318
3.720.504
3.742.628
3.764.752
742
W-1-11-i
1.631.104
1.645.784
1.655.570
1.665.357
743
W-1-11-ii
3.145.790
3.174.102
3.192.977
3.211.852
744
W-1-11-iii
5.575.679
5.625.860
5.659.314
5.692.768
745
W-1-12-i
1.140.079
1.150.340
1.157.180
1.164.021
746
W-1-12-ii
1.296.248
1.307.914
1.315.692
1.323.469
747
W-1-12-iii
1.991.201
2.009.121
2.021.069
2.033.016
748
W-1-13-i
1.356.964
1.369.176
1.377.318
1.385.460
749
W-1-13-ii
1.473.271
1.486.531
1.495.371
1.504.210
750
W-1-13-iii
1.978.875
1.996.685
2.008.559
2.020.432

SERVIK RINGAN
SERVIK SEDANG
SERVIK BERAT
ENDOSKOP RINGAN
ENDOSKOP SEDANG
ENDOSKOP BERAT
- 649 No
Kode
INA-CBG
751
W-1-20-i
752
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.806.541
4.849.800
4.878.639
4.907.479
W-1-20-ii
6.761.121
6.821.972
6.862.538
6.903.105
753
W-1-20-iii
8.541.202
8.618.073
8.669.320
8.720.567
754
W-1-30-i
2.018.377
2.036.542
2.048.652
2.060.762
755
W-1-30-ii
3.219.415
3.248.390
3.267.706
3.287.023
756
W-1-30-iii
8.561.217
8.638.268
8.689.635
8.741.002
757
W-4-10-i
1.505.203
1.518.750
1.527.781
1.536.813
758
W-4-10-ii
2.034.451
2.052.761
2.064.968
2.077.174
759
W-4-10-iii
4.598.959
4.640.349
4.667.943
4.695.537
760
W-4-11-i
1.437.175
1.450.109
1.458.732
1.467.355
761
W-4-11-ii
2.299.479
2.320.175
2.333.972
2.347.768
762
W-4-11-iii
2.794.549
2.819.700
2.836.467
2.853.234
763
W-4-12-i
1.149.740
1.160.087
1.166.986
1.173.884
764
W-4-12-ii
1.580.892
1.595.120
1.604.605
1.614.091
765
W-4-12-iii
1.762.519
1.778.382
1.788.957
1.799.532
766
W-4-13-i
ABORTUS RINGAN
630.531
636.206
639.989
643.772
767
W-4-13-ii
ABORTUS SEDANG
862.305
870.065
875.239
880.413
768
W-4-13-iii
ABORTUS BERAT
1.149.740
1.160.087
1.166.986
1.173.884
769
W-4-14-i
1.034.766
1.044.079
1.050.287
1.056.496
770
W-4-14-ii
1.330.876
1.342.854
1.350.839
1.358.824
771
W-4-14-iii
1.674.649
1.689.721
1.699.769
1.709.817
772
W-4-15-i
719.062
725.533
729.848
734.162
773
W-4-15-ii
799.734
806.931
811.730
816.528
774
W-4-15-iii
1.107.307
1.117.273
1.123.917
1.130.561
775
W-4-16-i
862.305
870.065
875.239
880.413
776
W-4-16-ii
1.149.740
1.160.087
1.166.986
1.173.884
777
W-4-16-iii
1.567.514
1.581.621
1.591.026
1.600.431
778
W-4-17-i
704.292
710.631
714.857
719.083
779
W-4-17-ii
1.149.740
1.160.087
1.166.986
1.173.884
780
W-4-17-iii
2.175.079
2.194.654
2.207.705
2.220.755
781
Z-4-10-i
REHABILITASI RINGAN
1.972.817
1.990.572
2.002.409
2.014.246
782
Z-4-10-ii
REHABILITASI SEDANG
2.618.630
2.642.198
2.657.909
2.673.621
783
Z-4-10-iii
REHABILITASI BERAT
3.720.014
3.753.494
3.775.814
3.798.134
784
Z-4-11-i
1.722.052
1.737.551
1.747.883
1.758.215

RINGAN
SEDANG
BERAT

- 650 No
Kode
INA-CBG
Deskripsi (INA-CBG)
785
Z-4-11-ii
786
Z-4-11-iii
787
Z-4-12-i
788
Z-4-12-ii
789
Z-4-12-iii
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.072.970
2.091.627
2.104.065
2.116.503
3.279.808
3.309.326
3.329.005
3.348.683
862.305
870.065
875.239
880.413
1.756.918
1.772.730
1.783.271
1.793.813
2.232.764
2.252.859
2.266.255
2.279.652

- 651 2. RawatJalan
No
Kode
INA-CBG
B-2-10-0
B-2-11-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
581.255
586.486
589.974
593.461
753.979
760.764
765.288
769.812
1.402.123
1.414.742
1.423.154
1.431.567
1.158.718
1.169.147
1.176.099
1.183.051
968.009
976.721
982.529
988.337
339.388
342.443
344.479
346.515

LAPAROSKOPI
PANKREAS
LAPAROSKOPI
EMPEDU
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
756.791
763.603
768.143
772.684
B-3-12-0

155.496
156.895
157.828
158.761
C-3-10-0
424.170
427.988
430.533
433.078
10
C-3-11-0

KANDUNG KEMIH
670.842
676.879
680.904
684.929
11
C-3-12-0
152.078
153.447
154.360
155.272
12
C-3-13-0
147.679
149.008
149.894
150.780
13
C-3-14-0
1.257.190
1.268.504
1.276.048
1.283.591
14
C-3-15-0
1.152.264
1.162.635
1.169.548
1.176.462
15
C-3-16-0
261.306
263.658
265.225
266.793
16
C-3-17-0

LEHER
173.343
174.903
175.943
176.983
17
C-3-18-0
76.853
77.544
78.005
78.467
18
C-3-19-0

MYELOMA ATAU TESTIS
108.685
109.663
110.316
110.968
19
C-3-20-0
2.164.470
2.183.951
2.196.937
2.209.924
20
C-3-21-0
124.029
125.146
125.890
126.634
21
C-3-22-0
544.555
549.456
552.723
555.990
22
C-3-23-0
88.206
89.000
89.529
90.058
23
D-2-10-0

TULANG
747.293
754.019
758.503
762.986
24
D-2-11-0
PROSEDUR LIMPA
935.739
944.161
949.775
955.389
25
D-2-21-0
784.820
791.883
796.592
801.301
26
D-2-22-0
172.244
173.795
174.828
175.862
27
D-3-10-0
124.761
125.884
126.632
127.381
28
D-3-11-0
323.915
326.830
328.774
330.717
29
E-2-10-0
192.144
193.873
195.026
196.179
30
E-2-21-0
139.298
140.551
141.387
142.223
31
E-2-22-0
139.298
140.551
141.387
142.223

OVARIUM
GASTROINTESTINAL
GINJAL ATAU PROSTAT

TYMUS
TYMUS
TULANG
PEMBENTUK DARAH
PARATIROID
THYROGLOSSAL
- 652 No
Kode
INA-CBG
32
E-3-10-0
33
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

ENDOKRIN
161.994
163.452
164.424
165.396
F-3-10-0
TERAPI SHOCK
225.977
228.011
229.367
230.722
34
F-5-10-0
276.895
279.387
281.048
282.710
35
F-5-11-0
TERAPI KELOMPOK
182.587
184.230
185.325
186.421
36
F-5-12-0
233.651
235.753
237.155
238.557
37
F-5-13-0
197.887
199.667
200.855
202.042
38
F-5-14-0
132.755
133.950
134.747
135.543
39
F-5-15-0
124.542
125.663
126.410
127.157
40
F-5-16-0
129.722
130.890
131.668
132.446
41
G-2-10-0
PROSEDUR KRANIOTOMI
109.236
110.219
110.875
111.530
42
G-2-11-0
946.903
955.426
961.107
966.788
43
G-2-12-0

EKSTRAKRANIAL
1.372.296
1.384.647
1.392.881
1.401.115
44
G-2-13-0
336.655
339.685
341.705
343.725
45
G-2-21-0
614.002
619.528
623.212
626.896
46
G-2-22-0
557.259
562.274
565.618
568.961
47
G-2-31-0
919.526
927.801
933.318
938.836
48
G-2-32-0
471.348
475.590
478.418
481.246
49
G-3-10-0
187.081
188.765
189.887
191.010
50
G-3-11-0
249.156
251.398
252.893
254.388
51
G-3-12-0
408.246
411.921
414.370
416.820
52
G-3-13-0
408.293
411.968
414.417
416.867
53
H-2-21-0
535.824
540.646
543.861
547.076
54
H-2-22-0
139.298
140.551
141.387
142.223
55
H-2-23-0
139.298
140.551
141.387
142.223
56
H-2-31-0
887.548
895.536
900.861
906.186
57
H-2-32-0
92.373
93.204
93.759
94.313
58
H-2-33-0
139.298
140.551
141.387
142.223
59
H-2-34-0
398.176
401.759
404.148
406.537
60
H-2-35-0
131.208
132.389
133.176
133.963
61
H-2-36-0
708.230
714.604
718.853
723.102
62
H-2-37-0

753.942
760.727
765.251
769.774
63
H-3-10-0
262.317
264.677
266.251
267.825
64
H-3-11-0
137.949
139.191
140.019
140.846

AKUT
MENTAL

MATA
MATA
MATA
MATA
MATA
- 653 No
Kode
INA-CBG
65
H-3-12-0
66
H-3-13-0
67
I-2-11-0
68
I-2-12-0
69
I-2-13-0
70
I-2-14-0
71
I-2-15-0
Deskripsi (INA-CBG)
MATA
TORASIK
ABDOMEN
PENGGANTIAN ALAT
DARAH VENA
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
144.026
145.322
146.187
147.051
139.841
141.099
141.938
142.778
1.612.662
1.627.176
1.636.852
1.646.528
1.133.878
1.144.083
1.150.886
1.157.689
1.441.090
1.454.060
1.462.707
1.471.353
2.550.423
2.573.377
2.588.679
2.603.982
153.377
154.758
155.678
156.598
1.610.915
1.625.413
1.635.078
1.644.744
531.072
535.852
539.038
542.225
72
I-2-16-0
73
I-2-17-0
74
I-2-21-0
1.243.397
1.254.588
1.262.048
1.269.508
75
I-2-22-0
1.170.876
1.181.414
1.188.439
1.195.465
76
I-2-23-0
239.616
241.773
243.211
244.648
77
I-2-31-0
1.863.577
1.880.349
1.891.531
1.902.712
78
I-2-32-0
2.436.900
2.458.833
2.473.454
2.488.075
79
I-2-41-0
1.633.972
1.648.677
1.658.481
1.668.285
80
I-2-42-0

LAIN
1.899.762
1.916.860
1.928.259
1.939.658
81
I-3-10-0
PROSEDUR RESUSITASI
241.158
243.328
244.775
246.222
82
I-3-11-0
127.283
128.428
129.192
129.956
83
I-3-12-0
739.719
746.376
750.814
755.253
84
I-3-13-0
242.952
245.139
246.597
248.054
85
I-3-14-0
155.724
157.126
158.060
158.994
137.949
139.191
140.019
140.846
854.094
861.781
866.906
872.030
137.680
138.919
139.745
140.571

PACU JANTUNG

KARDIOVASKULAR
PERNAFASAN
PENDEK
86
I-3-15-0
87
J-2-10-0
88
J-2-21-0
89
J-2-22-0
693.820
700.065
704.228
708.391
90
J-2-31-0
PROSEDUR
899.947
908.047
913.446
918.846
91
J-2-32-0
669.710
675.737
679.756
683.774
92
J-3-10-0
139.298
140.551
141.387
142.223
93
J-3-11-0

PADA DADA
393.631
397.173
399.535
401.897
94
J-3-12-0
152.078
153.447
154.360
155.272
95
J-3-13-0
223.821
225.836
227.179
228.522
96
J-3-14-0
237.611
239.749
241.175
242.601
- 654 No
Kode
INA-CBG
97
J-3-15-0
98
J-3-16-0
99
J-3-17-0
100
K-2-10-0
101
K-2-11-0
102
103
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
208.366
210.241
211.491
212.741
237.611
239.749
241.175
242.601
139.298
140.551
141.387
142.223
400.947
404.555
406.961
409.367
856.185
863.891
869.028
874.165
K-2-12-0

657.232
663.147
667.091
671.034
K-2-13-0
1.069.681
1.079.308
1.085.726
1.092.145
139.298
140.551
141.387
142.223
139.298
140.551
141.387
142.223
1.790.309
1.806.421
1.817.163
1.827.905
601.990
607.408
611.020
614.632
139.298
140.551
141.387
142.223

PERNAFASAN
KECIL

FEMORALIS
USUS BESAR
ATAS
ATAS
104
K-2-14-0
105
K-2-21-0
106
K-2-22-0
107
K-2-31-0
108
K-2-32-0
109
K-2-41-0
663.104
669.072
673.051
677.029
110
K-2-42-0

189.457
191.162
192.299
193.436
111
K-2-51-0
439.413
443.368
446.004
448.641
112
K-2-52-0
239.616
241.773
243.211
244.648
113
K-2-53-0
139.298
140.551
141.387
142.223
114
K-3-10-0

GASTROINTESTINAL
265.074
267.460
269.050
270.641
115
K-3-11-0
159.361
160.796
161.752
162.708
116
K-3-12-0
161.613
163.067
164.037
165.007
117
K-3-13-0
139.298
140.551
141.387
142.223
373.321
376.681
378.921
381.161
180.282
181.904
182.986
184.068
238.885
241.035
242.468
243.902
821.296
828.687
833.615
838.543
526.445
531.183
534.341
537.500
237.611
239.749
241.175
242.601
239.616
241.773
243.211
244.648

GASTROINTESTINAL
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
118
K-3-14-0
119
K-3-15-0
120
K-3-16-0
121
L-2-21-0
122
L-2-22-0
123
L-2-31-0
124
L-2-32-0
125
L-2-41-0
717.503
723.960
728.265
732.570
126
L-2-42-0

160.924
162.373
163.338
164.304
127
L-2-51-0
1.074.214
1.083.882
1.090.327
1.096.772
L-2-52-0

821.809
829.205
834.136
839.067
128
- 655 No
Kode
INA-CBG
129
L-2-53-0
130
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

139.298
140.551
141.387
142.223
L-3-10-0
189.457
191.162
192.299
193.436
131
L-3-11-0
183.976
185.632
186.735
187.839
132
L-3-12-0
140.115
141.376
142.217
143.058
133
M-2-10-0
1.098.999
1.108.890
1.115.484
1.122.078
134
M-2-21-0
984.230
993.088
998.993
1.004.898
135
M-2-22-0
239.616
241.773
243.211
244.648
136
M-2-31-0
PROSEDUR BUNION
597.821
603.201
606.788
610.375
137
M-2-32-0
189.457
191.162
192.299
193.436
138
M-2-41-0

TULANG
189.457
191.162
192.299
193.436
139
M-2-42-0
65.292
65.880
66.271
66.663
140
M-2-51-0
139.298
140.551
141.387
142.223
141
M-2-52-0
139.298
140.551
141.387
142.223
142
M-2-61-0
PROSEDUR ARTROSKOPI
682.771
688.916
693.013
697.110
143
M-2-62-0
139.298
140.551
141.387
142.223
686.465
692.643
696.762
700.881
936.196
944.622
950.239
955.857
139.298
140.551
141.387
142.223
691.159
697.379
701.526
705.673
666.998
673.001
677.003
681.005

DAN WAJAH
PAHA
PAHA

TULANG
WAJAH
WAJAH
BAWAH
BAWAH
144
M-2-63-0
145
M-2-64-0
146
M-2-65-0
147
M-2-71-0
148
M-2-72-0
149
M-2-81-0
994.636
1.003.588
1.009.555
1.015.523
150
M-2-82-0
722.539
729.042
733.377
737.713
151
M-2-83-0
139.298
140.551
141.387
142.223
152
M-2-84-0
139.298
140.551
141.387
142.223
153
M-3-10-0
397.583
401.161
403.547
405.932
154
M-3-11-0
220.435
222.419
223.742
225.065
155
M-3-12-0
498.498
502.984
505.975
508.966
156
M-3-13-0
162.524
163.986
164.962
165.937
157
M-3-14-0

TERTUTUP
277.781
280.281
281.947
283.614
158
M-3-15-0
122.379
123.481
124.215
124.949
159
M-3-16-0

139.298
140.551
141.387
142.223
160
M-3-17-0
152.078
153.447
154.360
155.272
161
N-2-11-0
1.840.261
1.856.823
1.867.865
1.878.906

PERGELANGAN TANGAN
PERGELANGAN TANGAN
MUSKULOSKELETAL
SKELETAL
- 656 No
Kode
INA-CBG
162
N-2-12-0
163
N-2-21-0
164
N-2-22-0
165
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.064.573
1.074.154
1.080.541
1.086.929
1.058.961
1.068.492
1.074.846
1.081.199
239.616
241.773
243.211
244.648
N-2-23-0
239.616
241.773
243.211
244.648
166
N-2-24-0
774.359
781.329
785.975
790.621
167
N-2-31-0
651.885
657.752
661.663
665.575
168
N-2-32-0
239.616
241.773
243.211
244.648
169
N-2-41-0
239.616
241.773
243.211
244.648
170
N-2-42-0
405.237
408.884
411.316
413.747
171
N-3-10-0
239.616
241.773
243.211
244.648
172
N-3-11-0
277.630
280.128
281.794
283.460
173
N-3-12-0
214.537
216.467
217.755
219.042
174
N-3-13-0
239.616
241.773
243.211
244.648
175
N-3-14-0
206.177
208.032
209.269
210.506
176
N-3-15-0
528.689
533.447
536.620
539.792
177
O-7-10-0
88.268
89.063
89.592
90.122
178
O-7-11-0
486.117
490.492
493.409
496.325
179
O-7-12-0
177.012
178.605
179.667
180.729
180
O-7-13-0
98.375
99.261
99.851
100.441
181
P-9-10-0
131.208
132.389
133.176
133.963
182
P-9-11-0
131.208
132.389
133.176
133.963
183
P-9-12-0
131.208
132.389
133.176
133.963
184
P-9-13-0
131.208
132.389
133.176
133.963
185
P-9-14-0
131.208
132.389
133.176
133.963
186
P-9-15-0
83.635
84.387
84.889
85.391
187
P-9-16-0
131.208
132.389
133.176
133.963
188
P-9-17-0
130.644
131.819
132.603
133.387
189
Q-5-10-0
171.006
172.545
173.571
174.597
190
Q-5-11-0
128.164
129.318
130.087
130.856
191
Q-5-12-0
GIGI
112.960
113.977
114.655
115.333
192
Q-5-13-0
MEDICAL CHECK-UP
85.845
86.618
87.133
87.648
193
Q-5-14-0
94.458
95.308
95.874
96.441


DAN URETHRA
DAN URETHRA
TRANSURETHRA
TRANSURETHRA
SALURAN KEMIH
KEMIH
KEMIH
PROSEDUR DIALISIS
CAESAR
VAGINAL/JALAN LAHIR

ASPIRASI
- 657 No
Kode
INA-CBG
194
Q-5-15-0
195
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
64.958
65.543
65.933
66.323
Q-5-16-0
VAKSINASI
73.418
74.079
74.519
74.960
196
Q-5-17-0
PASANG INFUS
63.505
64.076
64.457
64.838
197
Q-5-18-0
119.536
120.612
121.329
122.046
198
Q-5-19-0
133.634
134.836
135.638
136.440
199
Q-5-20-0
ABORSI MENGANCAM
89.570
90.376
90.914
91.451
200
Q-5-21-0
ABORSI
88.350
89.146
89.676
90.206
201
Q-5-22-0
94.458
95.308
95.874
96.441
202
Q-5-23-0
115.641
116.682
117.376
118.070
203
Q-5-24-0
78.981
79.692
80.166
80.640
204
Q-5-25-0
123.170
124.278
125.017
125.756
205
Q-5-26-0
BRONKIAL AKUT
174.338
175.907
176.953
177.999
206
Q-5-27-0
124.067
125.184
125.928
126.673
207
Q-5-28-0
100.677
101.584
102.188
102.792
208
Q-5-29-0

JANTUNG LAIN-LAIN
285.035
287.600
289.310
291.020
209
Q-5-30-0
330.324
333.297
335.279
337.261
210
Q-5-31-0
FRAKTUR
117.846
118.907
119.614
120.321
211
Q-5-32-0
SALURAN KEMIH AKUT
136.493
137.721
138.540
139.359
212
Q-5-33-0
HEMATOLOGI AKUT
142.907
144.194
145.051
145.909
213
Q-5-34-0
INFEKSI VIRUS HIV
203.010
204.837
206.055
207.273
214
Q-5-35-0
INFEKSI AKUT
230.208
232.280
233.661
235.042
215
Q-5-36-0
268.092
270.505
272.113
273.722
216
Q-5-37-0

SHOCK
136.741
137.971
138.792
139.612
217
Q-5-38-0
PARU AKUT
182.348
183.989
185.083
186.177
218
Q-5-39-0
116.689
117.739
118.440
119.140
219
Q-5-40-0
114.491
115.521
116.208
116.895
220
Q-5-41-0
158.496
159.923
160.874
161.825
221
Q-5-42-0
124.267
125.386
126.131
126.877
222
Q-5-43-0
178.952
180.563
181.637
182.710
223
Q-5-44-0
146.050
147.364
148.241
149.117
224
T-2-10-0

TERAPI DETOKSIKASI
75.754
76.435
76.890
77.344
225
U-2-10-0
1.011.018
1.020.117
1.026.183
1.032.249
226
U-2-11-0

LEHER
1.201.707
1.212.523
1.219.733
1.226.943
227
U-2-12-0
132.219
133.409
134.202
134.996
- 658 No
Kode
INA-CBG
228
U-2-13-0
229
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
173.343
174.903
175.943
176.983
U-2-14-0
321.992
324.890
326.822
328.754
230
U-2-15-0
182.949
184.595
185.693
186.791
231
U-2-21-0
213.107
215.025
216.303
217.582
232
U-2-22-0
411.739
415.445
417.916
420.386
233
U-2-23-0
539.512
544.367
547.604
550.841
234
U-2-24-0
454.691
458.783
461.511
464.240
235
U-2-25-0
173.343
174.903
175.943
176.983
236
U-2-31-0
139.298
140.551
141.387
142.223
237
U-2-32-0
173.343
174.903
175.943
176.983
238
U-3-10-0
165.725
167.216
168.211
169.205
239
U-3-11-0
175.948
177.531
178.587
179.643
240
U-3-12-0
77.804
78.504
78.971
79.438
241
U-3-13-0
171.019
172.558
173.584
174.611
242
U-3-14-0
157.131
158.545
159.488
160.431
243
U-3-15-0
137.032
138.266
139.088
139.910
244
U-3-16-0
PROSEDUR PADA GIGI
154.548
155.939
156.866
157.793
245
V-2-10-0

PROSTAT
1.507.792
1.521.362
1.530.409
1.539.456
246
V-2-11-0
170.041
171.571
172.591
173.612
542.624
547.507
550.763
554.019
239.616
241.773
243.211
244.648
239.616
241.773
243.211
244.648

(RHINOPLASTY)

RONGGA HIDUNG
TENGGOROKAN
PROSEDUR PADA PENIS

SKROTUM
SKROTUM
TRANSURETHRAL
247
V-2-12-0
248
V-2-13-0
249
V-2-14-0
250
V-2-15-0
SIRKUMSISI/SUNAT
131.208
132.389
133.176
133.963
251
V-3-10-0
273.643
276.106
277.747
279.389
252
V-3-11-0
578.897
584.107
587.580
591.053
253
V-3-12-0
334.212
337.220
339.225
341.231
254
W-2-10-0
122.379
123.481
124.215
124.949
255
W-2-11-0
312.756
315.571
317.447
319.324
256
W-2-12-0
578.897
584.107
587.580
591.053
257
W-2-13-0
92.845
93.680
94.237
94.794
258
W-2-21-0
1.163.736
1.174.210
1.181.192
1.188.175
259
W-2-22-0
122.379
123.481
124.215
124.949

PROSEDUR ABORSI
RAHIM & LEHER RAHIM
TERHALANG/TERGANGGU
TERHALANG/TERGANGGU
PANGGUL TERBUKA
PANGGUL TERBUKA
- 659 No
Kode
INA-CBG
260
W-2-23-0
Deskripsi (INA-CBG)
JALAN LAHIR
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
408.386
412.061
414.512
416.962
1.340.606
1.352.672
1.360.715
1.368.759
940.228
948.690
954.331
959.973
261
W-2-31-0
262
W-2-32-0
263
W-2-33-0
399.609
403.206
405.603
408.001
264
W-2-34-0
135.914
137.137
137.953
138.768
265
W-3-10-0
330.324
333.297
335.279
337.261
266
W-3-11-0
264.051
266.428
268.012
269.597
267
W-3-12-0
122.379
123.481
124.215
124.949
268
Z-3-10-0
1.385.497
1.397.966
1.406.279
1.414.592
269
Z-3-11-0

EMPEDU
1.058.961
1.068.492
1.074.846
1.081.199
270
Z-3-12-0
176.821
178.412
179.473
180.534
271
Z-3-13-0

LAIN-LAIN
1.079.010
1.088.721
1.095.195
1.101.669
272
Z-3-14-0
DIAGNOSTIK TIDUR
213.354
215.274
216.554
217.834
273
Z-3-15-0
139.298
140.551
141.387
142.223
274
Z-3-16-0

(MRI)
447.104
451.128
453.810
456.493
275
Z-3-17-0
PENGOBATAN NUKLIR
187.704
189.393
190.519
191.646
276
Z-3-18-0
CT-SCAN KEPALA
180.849
182.477
183.562
184.647
277
Z-3-19-0
CT SCAN LAIN-LAIN
188.229
189.923
191.052
192.181
278
Z-3-20-0
128.019
129.171
129.939
130.707
279
Z-3-21-0
122.379
123.481
124.215
124.949
280
Z-3-22-0
137.972
139.213
140.041
140.869
281
Z-3-23-0
143.709
145.003
145.865
146.727
282
Z-3-24-0
282.361
284.902
286.596
288.290
283
Z-3-25-0
125.763
126.895
127.649
128.404
284
Z-3-26-0
142.137
143.416
144.269
145.122
285
Z-3-27-0
PERAWATAN LUKA
135.702
136.924
137.738
138.552
286
Z-3-28-0
IMAGING PAYUDARA
139.298
140.551
141.387
142.223
287
Z-3-29-0
IMAGING LAIN-LAIN
401.481
405.095
407.504
409.913
288
Z-3-30-0
FOTOTERAPI
67.755
68.365
68.772
69.178
- 660 B. RUMAH SAKIT KHUSUS KELAS C

1. RUMAH SAKIT JIWAKELAS C
a. RawatInap
No
Kode
INA-CBG
A-4-10-i
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
SEPTIKEMIA RINGAN
1,958,974.14
2,017,743.36
2,056,922.85
2,096,102.33
A-4-10-ii
SEPTIKEMIA SEDANG
3,348,062.26
3,448,504.13
3,515,465.38
3,582,426.62
A-4-10-iii
SEPTIKEMIA BERAT
3,965,140.26
4,084,094.47
4,163,397.27
4,242,700.08
A-4-11-i
5,256,473.44
5,414,167.64
5,519,297.11
5,624,426.58
A-4-11-ii

SEDANG
8,120,644.07
8,364,263.40
8,526,676.28
8,689,089.16
A-4-11-iii
13,283,599.40
13,682,107.38
13,947,779.37
14,213,451.36
A-4-12-i
DEMAM RINGAN
1,532,985.91
1,578,975.49
1,609,635.21
1,640,294.93
A-4-12-ii
DEMAM SEDANG
2,957,525.54
3,046,251.30
3,105,401.82
3,164,552.33
A-4-12-iii
DEMAM BERAT
3,384,671.02
3,486,211.15
3,553,904.57
3,621,597.99
10
A-4-13-i
1,916,232.39
1,973,719.36
2,012,044.01
2,050,368.66
11
A-4-13-ii
2,299,478.87
2,368,463.24
2,414,452.81
2,460,442.39
12
A-4-13-iii
2,794,744.77
2,878,587.11
2,934,482.00
2,990,376.90
1,803,594.11
1,857,701.93
1,893,773.82
1,929,845.70
2,941,658.50
3,029,908.26
3,088,741.43
3,147,574.60
3,282,805.04
3,381,289.19
3,446,945.29
3,512,601.39

LAIN-LAIN RINGAN
LAIN-LAIN SEDANG
LAIN-LAIN BERAT
13
A-4-14-i
14
A-4-14-ii
15
A-4-14-iii
16
A-4-15-i
INFEKSI HIV RINGAN
2,411,055.76
2,483,387.43
2,531,608.54
2,579,829.66
17
A-4-15-ii
INFEKSI HIV SEDANG
3,449,218.30
3,552,694.85
3,621,679.22
3,690,663.59
18
A-4-15-iii
INFEKSI HIV BERAT
6,452,523.10
6,646,098.80
6,775,149.26
6,904,199.72
19
B-1-01-i
25,749,972.17
26,522,471.34
27,037,470.78
27,552,470.23
20
B-1-01-ii
28,409,103.60
29,261,376.71
29,829,558.78
30,397,740.85
21
B-1-01-iii
49,835,413.80
51,330,476.21
52,327,184.48
53,323,892.76
22
B-1-10-i
3,338,396.52
3,438,548.41
3,505,316.34
3,572,084.27
23
B-1-10-ii
8,507,842.28
8,763,077.55
8,933,234.40
9,103,391.24
24
B-1-10-iii
19,720,787.15
20,312,410.76
20,706,826.51
21,101,242.25
3,039,234.42
3,130,411.45
3,191,196.14
3,251,980.83
7,628,765.08
7,857,628.03
8,010,203.33
8,162,778.63
9,564,578.13
9,851,515.48
10,042,807.04
10,234,098.60
6,482,796.51
6,677,280.41
6,806,936.34
6,936,592.27
13,894,218.70
14,311,045.26
14,588,929.63
14,866,814.00
25
B-1-11-i
26
B-1-11-ii
27
B-1-11-iii
28
B-1-12-i
29
B-1-12-ii

(RINGAN)
(SEDANG)
(BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
- 661 No
Kode
INA-CBG
30
B-1-12-iii
31
B-1-13-i
32
B-1-13-ii
33
B-1-13-iii
34
B-1-14-i
35
B-1-14-ii
36
B-1-14-iii
37
B-4-10-i
38
39
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
16,519,164.84
17,014,739.78
17,345,123.08
17,675,506.38
4,248,032.27
4,375,473.24
4,460,433.89
4,545,394.53
6,919,428.10
7,127,010.94
7,265,399.50
7,403,788.07
10,201,178.59
10,507,213.94
10,711,237.52
10,915,261.09
5,768,528.92
5,941,584.79
6,056,955.37
6,172,325.95
6,415,768.29
6,608,241.34
6,736,556.70
6,864,872.07
10,036,706.83
10,337,808.03
10,538,542.17
10,739,276.31
1,613,946.58
1,662,364.98
1,694,643.91
1,726,922.84
B-4-10-ii
2,338,032.15
2,408,173.11
2,454,933.76
2,501,694.40
B-4-10-iii
3,940,735.33
4,058,957.39
4,137,772.10
4,216,586.81
3,896,672.07
4,013,572.23
4,091,505.67
4,169,439.12
5,923,914.58
6,101,632.02
6,220,110.31
6,338,588.60
6,380,261.78
6,571,669.63
6,699,274.87
6,826,880.10
3,419,062.72
3,521,634.60
3,590,015.85
3,658,397.11
4,847,389.69
4,992,811.38
5,089,759.17
5,186,706.97
9,212,351.16
9,488,721.69
9,672,968.71
9,857,215.74
2,299,478.87
2,368,463.24
2,414,452.81
2,460,442.39
3,347,637.06
3,448,066.17
3,515,018.91
3,581,971.65
5,531,991.53
5,697,951.27
5,808,591.10
5,919,230.93
2,960,896.91
3,049,723.82
3,108,941.76
3,168,159.70
3,327,231.92
3,427,048.87
3,493,593.51
3,560,138.15
4,232,555.93
4,359,532.61
4,444,183.73
4,528,834.85

LAPAROSKOPIK BERAT
LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT

PANCREAS RINGAN
PANCREAS SEDANG
PANCREAS BERAT
(RINGAN)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT
40
B-4-11-i
41
B-4-11-ii
42
B-4-11-iii
43
B-4-12-i
44
B-4-12-ii
45
B-4-12-iii
46
B-4-13-i
47
B-4-13-ii
48
B-4-13-iii
49
B-4-14-i
50
B-4-14-ii
51
B-4-14-iii
52
C-4-10-i
3,011,991.13
3,102,350.87
3,162,590.69
3,222,830.51
53
C-4-10-ii
5,851,982.92
6,027,542.41
6,144,582.06
6,261,621.72
54
C-4-10-iii
LEUKEMIA AKUT BERAT
8,636,093.03
8,895,175.82
9,067,897.68
9,240,619.54
55
C-4-11-i
3,030,052.87
3,120,954.45
3,181,555.51
3,242,156.57
56
C-4-11-ii
3,471,892.73
3,576,049.51
3,645,487.36
3,714,925.22
57
C-4-11-iii
7,011,360.61
7,221,701.43
7,361,928.64
7,502,155.86
58
C-4-12-i
RADIOTERAPI RINGAN
1,532,985.91
1,578,975.49
1,609,635.21
1,640,294.93
59
C-4-12-ii
RADIOTERAPI SEDANG
5,677,371.61
5,847,692.75
5,961,240.19
6,074,787.62
60
C-4-12-iii
RADIOTERAPI BERAT
11,526,202.01
11,871,988.07
12,102,512.11
12,333,036.15
61
C-4-13-i
KEMOTERAPI RINGAN
1,532,985.91
1,578,975.49
1,609,635.21
1,640,294.93
- 662 No
Kode
INA-CBG
62
C-4-13-ii
63
C-4-13-iii
64
C-4-14-i
65
C-4-14-ii
66
C-4-14-iii
67
D-1-10-i
68
D-1-10-ii
69
D-1-10-iii
70
D-1-11-i
71
72
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
KEMOTERAPI SEDANG
3,065,971.83
3,157,950.98
3,219,270.42
3,280,589.85
KEMOTERAPI BERAT
4,011,597.32
4,131,945.24
4,212,177.18
4,292,409.13
2,673,891.93
2,754,108.69
2,807,586.52
2,861,064.36
3,907,261.95
4,024,479.81
4,102,625.05
4,180,770.29
5,956,507.75
6,135,202.98
6,254,333.13
6,373,463.29
16,477,023.71
16,971,334.42
17,300,874.90
17,630,415.37
25,095,771.01
25,848,644.14
26,350,559.56
26,852,474.98
34,011,626.99
35,031,975.80
35,712,208.34
36,392,440.88
4,510,065.43
4,645,367.39
4,735,568.70
4,825,770.01
D-1-11-ii
10,325,328.95
10,635,088.81
10,841,595.39
11,048,101.97
D-1-11-iii
16,184,172.64
16,669,697.82
16,993,381.27
17,317,064.72
4,130,131.58
4,254,035.53
4,336,638.16
4,419,240.79
11,374,821.14
11,716,065.77
11,943,562.19
12,171,058.62
18,069,325.65
18,611,405.42
18,972,791.94
19,334,178.45

RINGAN
SEDANG
BERAT
TULANG RINGAN
TULANG SEDANG
TULANG BERAT

73
D-1-20-i
74
D-1-20-ii
75
D-1-20-iii
76
D-4-10-i
1,776,525.62
1,829,821.39
1,865,351.90
1,900,882.41
77
D-4-10-ii
2,973,309.31
3,062,508.59
3,121,974.77
3,181,440.96
78
D-4-10-iii
4,160,222.87
4,285,029.56
4,368,234.02
4,451,438.47
79
D-4-11-i
1,916,232.39
1,973,719.36
2,012,044.01
2,050,368.66
80
D-4-11-ii
4,339,440.87
4,469,624.09
4,556,412.91
4,643,201.73
81
D-4-11-iii
6,573,648.68
6,770,858.14
6,902,331.12
7,033,804.09
82
D-4-12-i
1,985,479.20
2,045,043.58
2,084,753.16
2,124,462.75
83
D-4-12-ii
2,754,054.74
2,836,676.39
2,891,757.48
2,946,838.58
84
D-4-12-iii
4,228,852.55
4,355,718.13
4,440,295.18
4,524,872.23
1,532,985.91
1,578,975.49
1,609,635.21
1,640,294.93
2,299,478.87
2,368,463.24
2,414,452.81
2,460,442.39
3,177,707.82
3,273,039.06
3,336,593.21
3,400,147.37
1,916,232.39
1,973,719.36
2,012,044.01
2,050,368.66
4,312,435.79
4,441,808.86
4,528,057.57
4,614,306.29
5,144,139.16
5,298,463.33
5,401,346.11
5,504,228.90
4,942,886.92
5,091,173.53
5,190,031.27
5,288,889.00
6,474,711.57
6,668,952.91
6,798,447.15
6,927,941.38
12,833,955.86
13,218,974.54
13,475,653.66
13,732,332.77
3,782,050.11
3,895,511.61
3,971,152.61
4,046,793.62
85
D-4-13-i
86
D-4-13-ii
87
D-4-13-iii
88
D-4-14-i
89
D-4-14-ii
90
D-4-14-iii
91
E-1-01-i
92
E-1-01-ii
93
E-1-01-iii
94
E-1-10-i

RINGAN
SEDANG
BERAT
- 663 No
Kode
INA-CBG
95
E-1-10-ii
96
E-1-10-iii
97
E-1-20-i
98
E-1-20-ii
99
E-1-20-iii
100
E-4-10-i
101
E-4-10-ii
102
E-4-10-iii
103
E-4-11-i
104
E-4-11-ii
105
E-4-11-iii
106
E-4-12-i
107
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4,590,521.13
4,728,236.76
4,820,047.19
4,911,857.61
9,675,467.11
9,965,731.13
10,159,240.47
10,352,749.81
5,832,414.30
6,007,386.72
6,124,035.01
6,240,683.30
7,811,576.57
8,045,923.87
8,202,155.40
8,358,386.93
17,308,246.08
17,827,493.46
18,173,658.39
18,519,823.31
2,393,202.89
2,464,998.98
2,512,863.03
2,560,727.09
3,665,788.30
3,775,761.95
3,849,077.72
3,922,393.48
6,217,830.68
6,404,365.60
6,528,722.21
6,653,078.83
2,199,170.99
2,265,146.12
2,309,129.54
2,353,112.96
4,160,453.84
4,285,267.45
4,368,476.53
4,451,685.61
6,860,780.11
7,066,603.51
7,203,819.11
7,341,034.71
2,107,855.63
2,171,091.30
2,213,248.41
2,255,405.52
E-4-12-ii
3,449,218.30
3,552,694.85
3,621,679.22
3,690,663.59
108
E-4-12-iii
5,541,579.22
5,707,826.59
5,818,658.18
5,929,489.76
109
E-4-13-i
2,771,711.31
2,854,862.65
2,910,296.87
2,965,731.10
110
E-4-13-ii
4,759,047.73
4,901,819.16
4,997,000.11
5,092,181.07
111
E-4-13-iii
8,234,354.50
8,481,385.14
8,646,072.23
8,810,759.32
112
F-4-10-i
SCHIZOFRENIA RINGAN
2,272,621.26
2,340,799.90
2,386,252.33
2,431,704.75
113
F-4-10-ii
SCHIZOFRENIA SEDANG
2,523,818.99
2,599,533.56
2,650,009.94
2,700,486.31
114
F-4-10-iii
SCHIZOFRENIA BERAT
3,736,569.68
3,848,666.77
3,923,398.16
3,998,129.56
115
F-4-11-i
2,094,806.31
2,157,650.50
2,199,546.62
2,241,442.75
116
F-4-11-ii
2,440,648.27
2,513,867.71
2,562,680.68
2,611,493.64
117
F-4-11-iii
DEPRESI MAYOR BERAT
3,129,803.04
3,223,697.13
3,286,293.19
3,348,889.25
118
F-4-12-i
1,149,739.43
1,184,231.62
1,207,226.41
1,230,221.20
119
F-4-12-ii
1,641,664.88
1,690,914.83
1,723,748.13
1,756,581.43
120
F-4-12-iii
3,561,316.48
3,668,155.97
3,739,382.30
3,810,608.63
121
F-4-13-i
1,692,921.78
1,743,709.44
1,777,567.87
1,811,426.31
122
F-4-13-ii
2,241,863.56
2,309,119.47
2,353,956.74
2,398,794.01
123
F-4-13-iii
2,890,596.75
2,977,314.66
3,035,126.59
3,092,938.53
124
F-4-14-i
DEPRESI RINGAN
1,185,045.39
1,220,596.75
1,244,297.66
1,267,998.57
125
F-4-14-ii
DEPRESI SEDANG
1,520,060.89
1,565,662.72
1,596,063.94
1,626,465.16
126
F-4-14-iii
DEPRESI BERAT
2,045,309.76
2,106,669.05
2,147,575.25
2,188,481.44
127
F-4-15-i
1,532,985.91
1,578,975.49
1,609,635.21
1,640,294.93

RINGAN
SEDANG
BERAT

RINGAN
SEDANG
BERAT

IMPULSE RINGAN
IMPULSE SEDANG
IMPULSE BERAT
- 664 No
Kode
INA-CBG
128
F-4-15-ii
129
F-4-15-iii
130
F-4-16-i
131
F-4-16-ii
132
F-4-16-iii
133
F-4-17-i
134
F-4-17-ii
135
F-4-17-iii
136
F-4-18-i
137
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2,299,478.87
2,368,463.24
2,414,452.81
2,460,442.39
3,028,554.71
3,119,411.35
3,179,982.45
3,240,553.54
3,034,605.63
3,125,643.80
3,186,335.91
3,247,028.03
3,527,653.00
3,633,482.59
3,704,035.65
3,774,588.71
4,708,827.90
4,850,092.73
4,944,269.29
5,038,445.85
776,757.75
800,060.48
815,595.64
831,130.79
2,276,602.96
2,344,901.05
2,390,433.11
2,435,965.17
2,428,967.87
2,501,836.91
2,550,416.26
2,598,995.62
2,630,293.85
2,709,202.66
2,761,808.54
2,814,414.42
F-4-18-ii
2,894,066.13
2,980,888.11
3,038,769.43
3,096,650.75
138
F-4-18-iii
4,461,455.22
4,595,298.87
4,684,527.98
4,773,757.08
139
F-4-19-i
2,017,187.17
2,077,702.79
2,118,046.53
2,158,390.28
140
F-4-19-ii
2,583,060.12
2,660,551.93
2,712,213.13
2,763,874.33
141
F-4-19-iii
3,215,944.38
3,312,422.71
3,376,741.59
3,441,060.48
7,181,218.05
7,396,654.59
7,540,278.95
7,683,903.31
12,155,077.02
12,519,729.33
12,762,830.87
13,005,932.41
23,530,871.55
24,236,797.69
24,707,415.13
25,178,032.56

RINGAN
SEDANG
BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT
142
G-1-01-i
143
G-1-01-ii
144
G-1-01-iii
145
G-1-10-i
4,772,515.18
4,915,690.63
5,011,140.93
5,106,591.24
146
G-1-10-ii
6,737,604.85
6,939,733.00
7,074,485.10
7,209,237.19
147
G-1-10-iii
7,985,500.93
8,225,065.96
8,384,775.98
8,544,486.00
148
G-1-11-i
5,505,238.74
5,670,395.90
5,780,500.67
5,890,605.45
149
G-1-11-ii
11,305,422.39
11,644,585.06
11,870,693.51
12,096,801.96
150
G-1-11-iii
20,650,657.89
21,270,177.63
21,683,190.78
22,096,203.94
4,281,453.75
4,409,897.37
4,495,526.44
4,581,155.52
9,292,796.05
9,571,579.93
9,757,435.85
9,943,291.77
13,739,952.28
14,152,150.84
14,426,949.89
14,701,748.93

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT
151
G-1-12-i
152
G-1-12-ii
153
G-1-12-iii
154
G-1-13-i
847,906.68
873,343.88
890,302.01
907,260.15
155
G-1-13-ii
2,277,383.67
2,345,705.18
2,391,252.85
2,436,800.53
156
G-1-13-iii
5,138,736.73
5,292,898.83
5,395,673.56
5,498,448.30
5,394,995.77
5,556,845.64
5,664,745.56
5,772,645.47
7,288,816.25
7,507,480.74
7,653,257.06
7,799,033.39
17,845,809.10
18,381,183.37
18,738,099.56
19,095,015.74
6,880,831.52
7,087,256.47
7,224,873.10
7,362,489.73
157
G-1-20-i
158
G-1-20-ii
159
G-1-20-iii
160
G-1-30-i

RINGAN
SEDANG
BERAT
- 665 No
Kode
INA-CBG
161
G-1-30-ii
162
G-1-30-iii
163
G-4-10-i
164
G-4-10-ii
165
G-4-10-iii
166
G-4-11-i
167
G-4-11-ii
168
G-4-11-iii
169
G-4-12-i
170
G-4-12-ii
171
G-4-12-iii
172
G-4-13-i
173
G-4-13-ii
174
G-4-13-iii
175
G-4-14-i
176
G-4-14-ii
177
G-4-14-iii
178
G-4-15-i
179
G-4-15-ii
180
G-4-15-iii
181
G-4-16-i
182
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
17,959,630.01
18,498,418.91
18,857,611.51
19,216,804.11
23,119,593.91
23,813,181.73
24,275,573.60
24,737,965.48
2,299,478.87
2,368,463.24
2,414,452.81
2,460,442.39
3,144,670.85
3,239,010.97
3,301,904.39
3,364,797.81
5,512,848.59
5,678,234.05
5,788,491.02
5,898,747.99
5,103,285.02
5,256,383.57
5,358,449.27
5,460,514.97
5,919,810.62
6,097,404.94
6,215,801.16
6,334,197.37
8,675,584.54
8,935,852.07
9,109,363.76
9,282,875.45
3,816,808.05
3,931,312.29
4,007,648.46
4,083,984.62
4,809,178.15
4,953,453.49
5,049,637.05
5,145,820.62
6,984,758.74
7,194,301.50
7,333,996.67
7,473,691.85
2,123,646.41
2,187,355.80
2,229,828.73
2,272,301.66
2,950,675.43
3,039,195.69
3,098,209.20
3,157,222.71
3,444,231.90
3,547,558.86
3,616,443.50
3,685,328.14
3,883,832.73
4,000,347.71
4,078,024.36
4,155,701.02
6,390,215.46
6,581,921.93
6,709,726.24
6,837,530.55
8,000,695.41
8,240,716.28
8,400,730.18
8,560,744.09
2,571,885.27
2,649,041.83
2,700,479.54
2,751,917.24
3,193,827.11
3,289,641.93
3,353,518.47
3,417,395.01
4,706,550.05
4,847,746.55
4,941,877.55
5,036,008.56
2,146,284.77
2,210,673.31
2,253,599.01
2,296,524.70
G-4-16-ii
3,105,354.86
3,198,515.51
3,260,622.60
3,322,729.70
183
G-4-16-iii
5,463,932.51
5,627,850.49
5,737,129.14
5,846,407.79
184
G-4-17-i
3,683,524.06
3,794,029.78
3,867,700.26
3,941,370.74
185
G-4-17-ii
4,571,415.53
4,708,558.00
4,799,986.31
4,891,414.62
186
G-4-17-iii
7,661,730.03
7,891,581.94
8,044,816.54
8,198,051.14
187
G-4-18-i
2,318,908.53
2,388,475.78
2,434,853.95
2,481,232.12
188
G-4-18-ii
4,434,875.88
4,567,922.16
4,656,619.67
4,745,317.19
189
G-4-18-iii
4,698,299.41
4,839,248.39
4,933,214.38
5,027,180.37
190
G-4-19-i
2,576,152.11
2,653,436.67
2,704,959.71
2,756,482.76

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
DEGENERATIF RINGAN
DEGENERATIF SEDANG
DEGENERATIF BERAT
RINGAN
SEDANG
BERAT
TRAUMATIK RINGAN
TRAUMATIK SEDANG
TRAUMATIK BERAT
DENGAN INFARK BERAT
TANPA INFARK RINGAN
TANPA INFARK SEDANG
TANPA INFARK BERAT

PERIFER RINGAN
PERIFER SEDANG
PERIFER BERAT
PERSARAFAN RINGAN
PERSARAFAN SEDANG
PERSARAFAN BERAT
RINGAN
- 666 No
Kode
INA-CBG
191
G-4-19-ii
192
G-4-19-iii
193
G-4-20-i
194
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4,563,228.57
4,700,125.43
4,791,390.00
4,882,654.57
6,491,903.31
6,686,660.41
6,816,498.48
6,946,336.54
1,512,849.53
1,558,235.02
1,588,492.01
1,618,749.00
G-4-20-ii
2,081,895.30
2,144,352.16
2,185,990.07
2,227,627.97
195
G-4-20-iii
3,438,704.80
3,541,865.94
3,610,640.04
3,679,414.13
196
G-4-21-i
2,090,736.40
2,153,458.49
2,195,273.22
2,237,087.94
197
G-4-21-ii
2,906,123.59
2,993,307.30
3,051,429.77
3,109,552.24
198
G-4-21-iii
5,101,396.81
5,254,438.71
5,356,466.65
5,458,494.59
199
G-4-22-i
1,532,985.91
1,578,975.49
1,609,635.21
1,640,294.93
200
G-4-22-ii
1,916,232.39
1,973,719.36
2,012,044.01
2,050,368.66
201
G-4-22-iii
2,198,419.50
2,264,372.08
2,308,340.47
2,352,308.86
202
G-4-23-i
1,885,561.09
1,942,127.92
1,979,839.15
2,017,550.37
203
G-4-23-ii
1,961,445.17
2,020,288.53
2,059,517.43
2,098,746.33
204
G-4-23-iii
2,792,615.98
2,876,394.46
2,932,246.78
2,988,099.10
205
G-4-24-i
1,578,632.83
1,625,991.82
1,657,564.48
1,689,137.13
206
G-4-24-ii
2,288,400.79
2,357,052.81
2,402,820.82
2,448,588.84
207
G-4-24-iii
TRAUMA KEPALA BERAT
4,420,171.94
4,552,777.09
4,641,180.53
4,729,583.97
208
G-4-25-i
GEGAR OTAK RINGAN
1,532,985.91
1,578,975.49
1,609,635.21
1,640,294.93
209
G-4-25-ii
GEGAR OTAK SEDANG
1,916,232.39
1,973,719.36
2,012,044.01
2,050,368.66
210
G-4-25-iii
GEGAR OTAK BERAT
2,392,780.25
2,464,563.66
2,512,419.26
2,560,274.87
211
G-4-26-i
3,107,470.74
3,200,694.86
3,262,844.27
3,324,993.69
212
G-4-26-ii
3,523,975.62
3,629,694.88
3,700,174.40
3,770,653.91
213
G-4-26-iii
5,172,504.53
5,327,679.67
5,431,129.76
5,534,579.85
214
H-1-20-i
2,963,934.52
3,052,852.56
3,112,131.25
3,171,409.94
215
H-1-20-ii
5,405,070.10
5,567,222.20
5,675,323.60
5,783,425.00
216
H-1-20-iii
7,350,557.61
7,571,074.34
7,718,085.49
7,865,096.64
217
H-1-30-i
2,901,974.17
2,989,033.39
3,047,072.88
3,105,112.36
218
H-1-30-ii
3,308,250.55
3,407,498.07
3,473,663.08
3,539,828.09
219
H-1-30-iii
5,519,696.38
5,685,287.27
5,795,681.20
5,906,075.13
220
H-4-10-i
2,628,702.62
2,707,563.69
2,760,137.75
2,812,711.80
221
H-4-10-ii
4,279,587.40
4,407,975.02
4,493,566.77
4,579,158.52
222
H-4-10-iii
6,719,491.96
6,921,076.72
7,055,466.56
7,189,856.39
223
H-4-11-i
2,106,016.57
2,169,197.07
2,211,317.40
2,253,437.73

SEDANG

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)

RINGAN
SEDANG
- 667 No
Kode
INA-CBG
224
H-4-11-ii
225
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2,324,637.92
2,394,377.06
2,440,869.82
2,487,362.58
H-4-11-iii
3,084,300.34
3,176,829.35
3,238,515.36
3,300,201.37
226
H-4-12-i
2,922,013.80
3,009,674.21
3,068,114.49
3,126,554.77
227
H-4-12-ii
3,958,058.82
4,076,800.58
4,155,961.76
4,235,122.93
228
H-4-12-iii
6,603,751.19
6,801,863.72
6,933,938.75
7,066,013.77
229
I-1-01-i
33,405,303.36
34,407,462.46
35,075,568.52
35,743,674.59
230
I-1-01-ii
34,140,394.20
35,164,606.03
35,847,413.91
36,530,221.80
231
I-1-01-iii
53,889,957.37
55,506,656.09
56,584,455.24
57,662,254.38
232
I-1-02-i
18,533,069.87
19,089,061.97
19,459,723.37
19,830,384.77
233
I-1-02-ii
23,907,660.14
24,624,889.94
25,103,043.14
25,581,196.35
234
I-1-02-iii
29,467,581.10
30,351,608.53
30,940,960.16
31,530,311.78
235
I-1-03-i
11,299,560.88
11,638,547.70
11,864,538.92
12,090,530.14
236
I-1-03-ii
15,487,993.42
15,952,633.22
16,262,393.09
16,572,152.96
237
I-1-03-iii
22,715,723.68
23,397,195.39
23,851,509.86
24,305,824.34
238
I-1-04-i
18,542,414.68
19,098,687.12
19,469,535.41
19,840,383.71
239
I-1-04-ii
23,818,060.95
24,532,602.78
25,008,964.00
25,485,325.22
240
I-1-04-iii
50,775,160.55
52,298,415.37
53,313,918.58
54,329,421.79
241
I-1-05-i
24,529,063.07
25,264,934.96
25,755,516.22
26,246,097.48
242
I-1-05-ii
29,434,875.68
30,317,921.95
30,906,619.47
31,495,316.98
243
I-1-05-iii
40,502,203.19
41,717,269.28
42,527,313.34
43,337,357.41
244
I-1-06-i
15,397,664.64
15,859,594.57
16,167,547.87
16,475,501.16
245
I-1-06-ii
20,148,910.16
20,753,377.47
21,156,355.67
21,559,333.87
246
I-1-06-iii
22,241,099.86
22,908,332.85
23,353,154.85
23,797,976.85
247
I-1-07-i
20,249,094.86
20,856,567.71
21,261,549.61
21,666,531.50
248
I-1-07-ii
24,981,372.03
25,730,813.19
26,230,440.64
26,730,068.08
249
I-1-07-iii
27,254,514.52
28,072,149.96
28,617,240.25
29,162,330.54
250
I-1-11-i
3,851,871.62
3,967,427.77
4,044,465.20
4,121,502.64
251
I-1-11-ii
4,282,896.06
4,411,382.94
4,497,040.86
4,582,698.78
252
I-1-11-iii
5,699,229.25
5,870,206.13
5,984,190.72
6,098,175.30

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
KATETERISASI RINGAN
KATETERISASI SEDANG
KATETERISASI BERAT
RINGAN
SEDANG
BERAT

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
RINGAN
SEDANG
BERAT
- 668 No
Kode
INA-CBG
253
I-1-12-i
254
I-1-12-ii
255
I-1-12-iii
256
I-1-13-i
257
I-1-13-ii
258
I-1-13-iii
259
I-1-14-i
260
I-1-14-ii
261
I-1-14-iii
262
I-1-15-i
263
264
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
9,845,958.00
10,141,336.74
10,338,255.90
10,535,175.06
13,281,516.99
13,679,962.49
13,945,592.83
14,211,223.17
18,137,291.05
18,681,409.78
19,044,155.60
19,406,901.42
6,014,556.37
6,194,993.06
6,315,284.19
6,435,575.31
6,762,841.74
6,965,726.99
7,100,983.83
7,236,240.66
14,727,989.67
15,169,829.37
15,464,389.16
15,758,948.95
19,078,160.16
19,650,504.97
20,032,068.17
20,413,631.38
23,711,427.63
24,422,770.46
24,896,999.01
25,371,227.57
31,070,146.55
32,002,250.95
32,623,653.88
33,245,056.81
6,071,236.99
6,253,374.10
6,374,798.84
6,496,223.58
I-1-15-ii
11,122,923.86
11,456,611.57
11,679,070.05
11,901,528.53
I-1-15-iii
19,193,218.03
19,769,014.57
20,152,878.93
20,536,743.29
8,176,354.36
8,421,644.99
8,585,172.07
8,748,699.16
21,258,521.33
21,896,276.97
22,321,447.39
22,746,617.82
24,521,182.67
25,256,818.15
25,747,241.80
26,237,665.46
3,492,000.57
3,596,760.58
3,666,600.59
3,736,440.61
7,233,199.17
7,450,195.14
7,594,859.12
7,739,523.11
41,933,688.80
43,191,699.47
44,030,373.24
44,869,047.02
5,517,258.67
5,682,776.43
5,793,121.60
5,903,466.77
9,292,796.05
9,571,579.93
9,757,435.85
9,943,291.77
17,912,118.63
18,449,482.19
18,807,724.56
19,165,966.94
9,276,116.49
9,554,399.99
9,739,922.32
9,925,444.65
19,296,196.28
19,875,082.17
20,261,006.09
20,646,930.02
29,902,095.93
30,799,158.81
31,397,200.73
31,995,242.65
16,611,943.01
17,110,301.30
17,442,540.16
17,774,779.02
21,413,419.98
22,055,822.58
22,484,090.98
22,912,359.38
25,753,516.51
26,526,122.00
27,041,192.33
27,556,262.66

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

DARAH VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
265
I-1-16-i
266
I-1-16-ii
267
I-1-16-iii
268
I-1-17-i
269
I-1-17-ii
270
I-1-17-iii
271
I-1-20-i
272
I-1-20-ii
273
I-1-20-iii
274
I-1-30-i
275
I-1-30-ii
276
I-1-30-iii
277
I-1-40-i
278
I-1-40-ii
279
I-1-40-iii
280
I-4-10-i
4,831,235.65
4,976,172.72
5,072,797.43
5,169,422.15
281
I-4-10-ii
7,628,607.86
7,857,466.10
8,010,038.26
8,162,610.41
- 669 No
Kode
INA-CBG
282
I-4-10-iii
283
I-4-11-i
284
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
11,004,932.39
11,335,080.36
11,555,179.01
11,775,277.66
4,940,497.82
5,088,712.75
5,187,522.71
5,286,332.67
I-4-11-ii
5,748,697.17
5,921,158.09
6,036,132.03
6,151,105.98
285
I-4-11-iii
9,327,245.92
9,607,063.30
9,793,608.22
9,980,153.14
286
I-4-12-i
5,017,642.56
5,168,171.83
5,268,524.68
5,368,877.54
287
I-4-12-ii
7,160,161.65
7,374,966.50
7,518,169.73
7,661,372.96
288
I-4-12-iii
8,686,283.32
8,946,871.82
9,120,597.49
9,294,323.15
289
I-4-13-i
4,507,222.33
4,642,439.00
4,732,583.44
4,822,727.89
290
I-4-13-ii
6,548,074.25
6,744,516.47
6,875,477.96
7,006,439.44
291
I-4-13-iii
10,776,448.20
11,099,741.64
11,315,270.61
11,530,799.57
292
I-4-14-i
2,803,075.94
2,887,168.21
2,943,229.73
2,999,291.25
293
I-4-14-ii
3,280,013.36
3,378,413.76
3,444,014.03
3,509,614.29
294
I-4-14-iii
5,082,929.54
5,235,417.42
5,337,076.02
5,438,734.61
3,065,971.83
3,157,950.98
3,219,270.42
3,280,589.85
5,903,775.80
6,080,889.07
6,198,964.59
6,317,040.10
6,728,883.96
6,930,750.48
7,065,328.16
7,199,905.84

VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT

295
I-4-15-i
296
I-4-15-ii
297
I-4-15-iii
298
I-4-16-i
2,387,212.50
2,458,828.88
2,506,573.13
2,554,317.38
299
I-4-16-ii
3,828,765.70
3,943,628.67
4,020,203.99
4,096,779.30
300
I-4-16-iii
4,806,784.69
4,950,988.23
5,047,123.93
5,143,259.62
301
I-4-17-i
HIPERTENSI RINGAN
2,768,201.69
2,851,247.74
2,906,611.77
2,961,975.80
302
I-4-17-ii
HIPERTENSI SEDANG
3,776,330.93
3,889,620.86
3,965,147.47
4,040,674.09
303
I-4-17-iii
HIPERTENSI BERAT
4,413,772.65
4,546,185.83
4,634,461.28
4,722,736.74
4,076,765.87
4,199,068.85
4,280,604.16
4,362,139.48
6,245,332.51
6,432,692.48
6,557,599.13
6,682,505.78
8,419,709.17
8,672,300.44
8,840,694.63
9,009,088.81
3,190,603.60
3,286,321.71
3,350,133.78
3,413,945.86
5,179,482.73
5,334,867.22
5,438,456.87
5,542,046.53
5,932,932.54
6,110,920.52
6,229,579.17
6,348,237.82

RINGAN
SEDANG
KONGENITAL BERAT
RINGAN
SEDANG
BERAT
304
I-4-18-i
305
I-4-18-ii
306
I-4-18-iii
307
I-4-19-i
308
I-4-19-ii
309
I-4-19-iii
310
I-4-20-i
3,872,249.55
3,988,417.03
4,065,862.02
4,143,307.02
311
I-4-20-ii
4,461,120.74
4,594,954.36
4,684,176.78
4,773,399.19
312
I-4-20-iii
5,920,649.60
6,098,269.09
6,216,682.09
6,335,095.08
313
I-4-21-i
5,149,465.01
5,303,948.96
5,406,938.26
5,509,927.56
314
I-4-21-ii
6,423,623.61
6,616,332.32
6,744,804.79
6,873,277.26
- 670 No
Kode
INA-CBG
315
I-4-21-iii
316
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
8,763,184.77
9,026,080.31
9,201,344.00
9,376,607.70
I-4-22-i
2,491,102.11
2,565,835.17
2,615,657.21
2,665,479.26
317
I-4-22-ii
2,870,495.28
2,956,610.14
3,014,020.05
3,071,429.95
318
I-4-22-iii
4,187,974.60
4,313,613.84
4,397,373.33
4,481,132.82
1,906,150.04
1,963,334.54
2,001,457.54
2,039,580.54
2,340,312.93
2,410,522.32
2,457,328.58
2,504,134.84
4,572,758.12
4,709,940.86
4,801,396.02
4,892,851.19
3,027,590.44
3,118,418.15
3,178,969.96
3,239,521.77
7,559,055.80
7,785,827.47
7,937,008.59
8,088,189.71
9,557,060.57
9,843,772.38
10,034,913.59
10,226,054.81
24,392,366.23
25,124,137.22
25,611,984.55
26,099,831.87
26,058,276.30
26,840,024.59
27,361,190.11
27,882,355.64
44,520,718.29
45,856,339.84
46,746,754.21
47,637,168.58
12,468,893.91
12,842,960.73
13,092,338.60
13,341,716.48
13,357,507.62
13,758,232.85
14,025,383.00
14,292,533.16
19,738,590.18
20,330,747.88
20,725,519.68
21,120,291.49
4,865,542.68
5,011,508.96
5,108,819.82
5,206,130.67
11,752,053.75
12,104,615.36
12,339,656.44
12,574,697.51
17,770,073.63
18,303,175.84
18,658,577.32
19,013,978.79
4,130,131.58
4,254,035.53
4,336,638.16
4,419,240.79
6,116,401.47
6,299,893.51
6,422,221.54
6,544,549.57
8,025,239.04
8,265,996.21
8,426,500.99
8,587,005.77
2,835,923.77
2,921,001.48
2,977,719.96
3,034,438.43
12,170,050.38
12,535,151.89
12,778,552.90
13,021,953.91
33,195,027.53
34,190,878.36
34,854,778.91
35,518,679.46

RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
319
I-4-23-i
320
I-4-23-ii
321
I-4-23-iii
322
I-4-24-i
323
I-4-24-ii
324
I-4-24-iii
325
J-1-01-i
326
J-1-01-ii
327
J-1-01-iii
328
J-1-02-i
329
J-1-02-ii
330
J-1-02-iii
331
J-1-10-i
332
J-1-10-ii
333
J-1-10-iii
334
J-1-20-i
335
J-1-20-ii
336
J-1-20-iii
337
J-1-30-i
338
J-1-30-ii
339
J-1-30-iii
340
J-4-10-i
2,457,796.13
2,531,530.02
2,580,685.94
2,629,841.86
341
J-4-10-ii
3,514,353.21
3,619,783.81
3,690,070.87
3,760,357.93
342
J-4-10-iii
5,316,691.75
5,476,192.50
5,582,526.34
5,688,860.17
343
J-4-11-i
2,064,868.51
2,126,814.56
2,168,111.93
2,209,409.30
344
J-4-11-ii
2,874,249.79
2,960,477.28
3,017,962.28
3,075,447.27
345
J-4-11-iii
4,118,873.32
4,242,439.51
4,324,816.98
4,407,194.45
- 671 No
Kode
INA-CBG
346
J-4-12-i
347
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
EMBOLI PARU RINGAN
2,371,203.80
2,442,339.91
2,489,763.99
2,537,188.06
J-4-12-ii
EMBOLI PARU SEDANG
3,070,627.87
3,162,746.70
3,224,159.26
3,285,571.82
348
J-4-12-iii
EMBOLI PARU BERAT
4,100,513.18
4,223,528.57
4,305,538.83
4,387,549.10
349
J-4-13-i
4,864,088.17
5,010,010.81
5,107,292.57
5,204,574.34
350
J-4-13-ii
7,150,209.60
7,364,715.89
7,507,720.08
7,650,724.28
351
J-4-13-iii
11,625,170.72
11,973,925.84
12,206,429.25
12,438,932.67
352
J-4-14-i
TUMOR PARU RINGAN
3,314,722.40
3,414,164.07
3,480,458.52
3,546,752.97
353
J-4-14-ii
TUMOR PARU SEDANG
5,552,613.64
5,719,192.05
5,830,244.32
5,941,296.60
354
J-4-14-iii
TUMOR PARU BERAT
6,601,775.44
6,799,828.70
6,931,864.21
7,063,899.72
2,901,913.30
2,988,970.70
3,047,008.97
3,105,047.23
4,086,066.37
4,208,648.36
4,290,369.68
4,372,091.01
5,134,665.46
5,288,705.42
5,391,398.73
5,494,092.04
1,982,197.60
2,041,663.53
2,081,307.48
2,120,951.43
3,411,455.58
3,513,799.25
3,582,028.36
3,650,257.47
5,589,797.22
5,757,491.14
5,869,287.09
5,981,083.03

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
355
J-4-15-i
356
J-4-15-ii
357
J-4-15-iii
358
J-4-16-i
359
J-4-16-ii
360
J-4-16-iii
361
J-4-17-i
2,375,778.23
2,447,051.58
2,494,567.14
2,542,082.71
362
J-4-17-ii
3,224,620.63
3,321,359.25
3,385,851.66
3,450,344.07
363
J-4-17-iii
5,172,012.10
5,327,172.46
5,430,612.70
5,534,052.94
364
J-4-18-i
1,610,152.60
1,658,457.17
1,690,660.23
1,722,863.28
365
J-4-18-ii
2,463,533.47
2,537,439.48
2,586,710.15
2,635,980.81
366
J-4-18-iii
2,576,244.15
2,653,531.48
2,705,056.36
2,756,581.24
367
J-4-19-i
3,010,700.51
3,101,021.53
3,161,235.54
3,221,449.55
368
J-4-19-ii
4,086,036.24
4,208,617.33
4,290,338.05
4,372,058.78
369
J-4-19-iii
5,840,758.99
6,015,981.76
6,132,796.94
6,249,612.12
370
J-4-20-i
3,323,435.42
3,423,138.49
3,489,607.19
3,556,075.90
371
J-4-20-ii
4,401,752.00
4,533,804.56
4,621,839.59
4,709,874.63
372
J-4-20-iii
8,773,869.52
9,037,085.60
9,212,562.99
9,388,040.38
1,849,899.99
1,905,396.99
1,942,394.99
1,979,392.99
4,121,714.55
4,245,365.99
4,327,800.28
4,410,234.57
5,750,383.99
5,922,895.51
6,037,903.19
6,152,910.87
4,130,131.58
4,254,035.53
4,336,638.16
4,419,240.79
7,752,994.78
7,985,584.62
8,140,644.52
8,295,704.41
9,080,091.83
9,352,494.58
9,534,096.42
9,715,698.25
373
J-4-21-i
374
J-4-21-ii
375
J-4-21-iii
376
K-1-10-i
377
K-1-10-ii
378
K-1-10-iii

USUS BESAR (RINGAN)
USUS BESAR (SEDANG)
USUS BESAR (BERAT)
- 672 No
Kode
INA-CBG
Deskripsi (INA-CBG)
379
K-1-11-i
380
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4,776,832.24
4,920,137.20
5,015,673.85
5,111,210.49
K-1-11-ii
6,271,404.14
6,459,546.26
6,584,974.35
6,710,402.43
381
K-1-11-iii
15,915,589.41
16,393,057.09
16,711,368.88
17,029,680.67
382
K-1-12-i
2,569,570.08
2,646,657.19
2,698,048.59
2,749,439.99
383
K-1-12-ii
3,348,944.70
3,449,413.04
3,516,391.93
3,583,370.82
384
K-1-12-iii
6,661,755.17
6,861,607.83
6,994,842.93
7,128,078.03
385
K-1-13-i
2,918,679.49
3,006,239.87
3,064,613.46
3,122,987.05
386
K-1-13-ii
5,098,094.68
5,251,037.52
5,352,999.42
5,454,961.31
387
K-1-13-iii
5,452,228.30
5,615,795.15
5,724,839.71
5,833,884.28
388
K-1-14-i
4,716,758.67
4,858,261.43
4,952,596.60
5,046,931.78
389
K-1-14-ii
5,540,367.41
5,706,578.43
5,817,385.78
5,928,193.13
390
K-1-14-iii
13,072,785.43
13,464,968.99
13,726,424.70
13,987,880.41
391
K-1-20-i
9,151,895.52
9,426,452.39
9,609,490.30
9,792,528.21
392
K-1-20-ii
12,773,632.62
13,156,841.60
13,412,314.25
13,667,786.91
393
K-1-20-iii
26,173,143.07
26,958,337.36
27,481,800.22
28,005,263.08
394
K-1-30-i
6,024,233.10
6,204,960.10
6,325,444.76
6,445,929.42
395
K-1-30-ii
8,260,263.16
8,508,071.05
8,673,276.31
8,838,481.58
396
K-1-30-iii
17,303,799.90
17,822,913.90
18,168,989.90
18,515,065.89
397
K-1-40-i
6,052,069.42
6,233,631.50
6,354,672.89
6,475,714.28
398
K-1-40-ii
6,659,701.24
6,859,492.27
6,992,686.30
7,125,880.32
399
K-1-40-iii
11,044,473.26
11,375,807.46
11,596,696.92
11,817,586.39
400
K-1-50-i
4,616,268.77
4,754,756.83
4,847,082.21
4,939,407.58
401
K-1-50-ii
5,978,285.78
6,157,634.35
6,277,200.07
6,396,765.78
402
K-1-50-iii
PROSEDUR ANAL BERAT
8,487,575.85
8,742,203.13
8,911,954.64
9,081,706.16
403
K-4-10-i
3,496,491.50
3,601,386.25
3,671,316.08
3,741,245.91
404
K-4-10-ii
4,183,757.43
4,309,270.15
4,392,945.30
4,476,620.45
405
K-4-10-iii
14,096,567.82
14,519,464.86
14,801,396.21
15,083,327.57
406
K-4-11-i
1,727,328.83
1,779,148.70
1,813,695.27
1,848,241.85
407
K-4-11-ii
2,803,359.72
2,887,460.51
2,943,527.70
2,999,594.90
408
K-4-11-iii
4,701,785.08
4,842,838.63
4,936,874.33
5,030,910.03
409
K-4-12-i
1,763,609.93
1,816,518.23
1,851,790.42
1,887,062.62
410
K-4-12-ii
3,080,630.21
3,173,049.12
3,234,661.72
3,296,274.33
411
K-4-12-iii
6,777,516.93
6,980,842.43
7,116,392.77
7,251,943.11


RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
- 673 No
Kode
INA-CBG
412
K-4-13-i
413
K-4-13-ii
414
K-4-13-iii
415
K-4-14-i
416
K-4-14-ii
417
K-4-14-iii
418
K-4-15-i
419
K-4-15-ii
420
K-4-15-iii
421
K-4-16-i
422
K-4-16-ii
423
K-4-16-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2,425,848.22
2,498,623.67
2,547,140.64
2,595,657.60
3,111,595.86
3,204,943.74
3,267,175.65
3,329,407.57
5,023,607.47
5,174,315.69
5,274,787.84
5,375,259.99
1,998,030.24
2,057,971.15
2,097,931.75
2,137,892.36
2,682,036.21
2,762,497.30
2,816,138.02
2,869,778.75
4,708,801.67
4,850,065.72
4,944,241.76
5,038,417.79
2,110,232.38
2,173,539.35
2,215,744.00
2,257,948.65
3,814,022.12
3,928,442.78
4,004,723.23
4,081,003.67
5,352,797.15
5,513,381.06
5,620,437.01
5,727,492.95
2,121,522.01
2,185,167.67
2,227,598.11
2,270,028.55
2,809,371.56
2,893,652.70
2,949,840.13
3,006,027.57
3,775,450.29
3,888,713.80
3,964,222.80
4,039,731.81
1,532,985.91
1,578,975.49
1,609,635.21
1,640,294.93
3,008,529.92
3,098,785.82
3,158,956.42
3,219,127.01
3,657,327.89
3,767,047.72
3,840,194.28
3,913,340.84
2,055,306.86
2,116,966.06
2,158,072.20
2,199,178.34
3,201,114.96
3,297,148.41
3,361,170.71
3,425,193.01
3,722,156.61
3,833,821.31
3,908,264.44
3,982,707.57
21,101,198.69
21,734,234.65
22,156,258.62
22,578,282.60
21,733,020.41
22,385,011.03
22,819,671.43
23,254,331.84
30,459,720.39
31,373,512.00
31,982,706.41
32,591,900.82
7,227,730.26
7,444,562.17
7,589,116.77
7,733,671.38
13,863,454.20
14,279,357.83
14,556,626.91
14,833,895.99
14,621,618.46
15,060,267.01
15,352,699.38
15,645,131.75
3,864,443.83
3,980,377.15
4,057,666.02
4,134,954.90
8,260,263.16
8,508,071.05
8,673,276.31
8,838,481.58
11,849,688.42
12,205,179.07
12,442,172.84
12,679,166.61

(RINGAN)
(SEDANG)
RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
424
K-4-17-i
425
K-4-17-ii
426
K-4-17-iii
427
K-4-18-i
428
K-4-18-ii
429
K-4-18-iii
430
L-1-20-i
431
L-1-20-ii
432
L-1-20-iii
433
L-1-30-i
434
L-1-30-ii
435
L-1-30-iii
436
L-1-40-i
437
L-1-40-ii
438
L-1-40-iii
439
L-1-50-i
5,162,664.47
5,317,544.41
5,420,797.70
5,524,050.99
440
L-1-50-ii
9,292,796.05
9,571,579.93
9,757,435.85
9,943,291.77
441
L-1-50-iii
11,236,305.24
11,573,394.39
11,798,120.50
12,022,846.60
442
L-4-10-i
2,547,984.19
2,624,423.72
2,675,383.40
2,726,343.09
- 674 No
Kode
INA-CBG
443
L-4-10-ii
444
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3,546,831.59
3,653,236.54
3,724,173.17
3,795,109.80
L-4-10-iii
7,299,768.19
7,518,761.24
7,664,756.60
7,810,751.97
445
L-4-11-i
2,925,447.19
3,013,210.61
3,071,719.55
3,130,228.49
446
L-4-11-ii
4,007,811.47
4,128,045.82
4,208,202.05
4,288,358.28
447
L-4-11-iii
10,868,683.51
11,194,744.01
11,412,117.68
11,629,491.36
448
L-4-12-i
2,887,931.76
2,974,569.72
3,032,328.35
3,090,086.99
449
L-4-12-ii
4,538,199.01
4,674,344.99
4,765,108.97
4,855,872.95
450
L-4-12-iii
7,349,450.81
7,569,934.34
7,716,923.35
7,863,912.37
451
L-4-13-i
1,941,404.27
1,999,646.40
2,038,474.48
2,077,302.57
452
L-4-13-ii
2,238,553.63
2,305,710.24
2,350,481.31
2,395,252.38
453
L-4-13-iii
3,358,005.11
3,458,745.26
3,525,905.36
3,593,065.46
454
L-4-14-i
1,769,206.61
1,822,282.80
1,857,666.94
1,893,051.07
455
L-4-14-ii
2,629,497.27
2,708,382.19
2,760,972.13
2,813,562.08
456
L-4-14-iii
4,836,014.86
4,981,095.31
5,077,815.61
5,174,535.90
457
M-1-01-i
7,549,150.07
7,775,624.58
7,926,607.58
8,077,590.58
458
M-1-01-ii
8,426,072.72
8,678,854.90
8,847,376.36
9,015,897.81
459
M-1-01-iii
11,836,349.31
12,191,439.79
12,428,166.78
12,664,893.76
460
M-1-02-i
7,120,204.85
7,333,811.00
7,476,215.10
7,618,619.19
461
M-1-02-ii
11,690,022.76
12,040,723.44
12,274,523.89
12,508,324.35
462
M-1-02-iii
20,086,808.16
20,689,412.41
21,091,148.57
21,492,884.74
13,422,927.63
13,825,615.46
14,094,074.01
14,362,532.56
15,708,750.75
16,180,013.27
16,494,188.29
16,808,363.30
20,443,228.62
21,056,525.48
21,465,390.05
21,874,254.62
4,696,985.71
4,837,895.28
4,931,834.99
5,025,774.71
6,021,486.96
6,202,131.57
6,322,561.31
6,442,991.05
7,534,755.86
7,760,798.53
7,911,493.65
8,062,188.77
7,317,001.84
7,536,511.90
7,682,851.93
7,829,191.97
8,456,493.40
8,710,188.20
8,879,318.07
9,048,447.94
14,403,711.35
14,835,822.69
15,123,896.91
15,411,971.14
6,065,162.16
6,247,117.03
6,368,420.27
6,489,723.52
8,125,421.98
8,369,184.64
8,531,693.08
8,694,201.52
16,552,254.96
17,048,822.61
17,379,867.70
17,710,912.80
463
M-1-03-i
464
M-1-03-ii
465
M-1-03-iii
466
M-1-04-i
467
M-1-04-ii
468
M-1-04-iii
469
M-1-05-i
470
M-1-05-ii
471
M-1-05-iii
472
M-1-07-i
473
M-1-07-ii
474
M-1-07-iii


- 675 No
Kode
INA-CBG
475
M-1-10-i
476
M-1-10-ii
477
M-1-10-iii
478
M-1-20-i
479
M-1-20-ii
480
M-1-20-iii
481
M-1-30-i
482
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5,047,935.86
5,199,373.93
5,300,332.65
5,401,291.37
18,750,794.28
19,313,318.11
19,688,333.99
20,063,349.88
21,862,082.55
22,517,945.03
22,955,186.68
23,392,428.33
4,993,712.78
5,143,524.16
5,243,398.42
5,343,272.67
7,128,076.82
7,341,919.13
7,484,480.66
7,627,042.20
13,855,427.49
14,271,090.31
14,548,198.86
14,825,307.41
2,986,986.80
3,076,596.41
3,136,336.14
3,196,075.88
M-1-30-ii
6,171,874.43
6,357,030.67
6,480,468.16
6,603,905.64
483
M-1-30-iii
PROSEDUR KAKI BERAT
9,207,135.31
9,483,349.37
9,667,492.07
9,851,634.78
484
M-1-40-i
2,949,650.73
3,038,140.25
3,097,133.26
3,156,126.28
485
M-1-40-ii
4,854,990.56
5,000,640.27
5,097,740.09
5,194,839.90
486
M-1-40-iii
7,227,730.26
7,444,562.17
7,589,116.77
7,733,671.38
487
M-1-50-i
3,997,116.96
4,117,030.47
4,196,972.81
4,276,915.15
488
M-1-50-ii
7,227,730.26
7,444,562.17
7,589,116.77
7,733,671.38
489
M-1-50-iii
8,260,263.16
8,508,071.05
8,673,276.31
8,838,481.58
490
M-1-60-i
3,016,562.08
3,107,058.94
3,167,390.18
3,227,721.42
491
M-1-60-ii
6,039,176.92
6,220,352.23
6,341,135.77
6,461,919.31
492
M-1-60-iii
10,510,304.12
10,825,613.24
11,035,819.32
11,246,025.40
493
M-1-70-i
4,040,980.27
4,162,209.68
4,243,029.29
4,323,848.89
494
M-1-70-ii
8,245,601.09
8,492,969.12
8,657,881.15
8,822,793.17
495
M-1-70-iii
13,292,904.97
13,691,692.12
13,957,550.22
14,223,408.32
496
M-1-80-i
3,255,936.44
3,353,614.54
3,418,733.27
3,483,851.99
497
M-1-80-ii
4,922,310.12
5,069,979.42
5,168,425.63
5,266,871.83
498
M-1-80-iii
11,332,433.00
11,672,405.99
11,899,054.65
12,125,703.31
499
M-4-10-i
1,753,463.68
1,806,067.59
1,841,136.86
1,876,206.14
500
M-4-10-ii
3,146,129.18
3,240,513.06
3,303,435.64
3,366,358.23
501
M-4-10-iii
FRAKTUR FEMUR BERAT
6,680,638.83
6,881,058.00
7,014,670.78
7,148,283.55
502
M-4-11-i
2,728,982.31
2,810,851.77
2,865,431.42
2,920,011.07
503
M-4-11-ii
6,260,692.16
6,448,512.93
6,573,726.77
6,698,940.62
504
M-4-11-iii
11,112,581.96
11,445,959.42
11,668,211.06
11,890,462.70
505
M-4-12-i
1,532,985.91
1,578,975.49
1,609,635.21
1,640,294.93

TULANG WAJAH RINGAN
TULANG WAJAH SEDANG
TULANG WAJAH BERAT

RINGAN
SEDANG
BERAT

SELAIN KAKI (BERAT)

PANGGUL RINGAN
PANGGUL SEDANG
PANGGUL BERAT
PELVIS RINGAN
- 676 No
Kode
INA-CBG
506
M-4-12-ii
507
M-4-12-iii
508
M-4-13-i
509
M-4-13-ii
510
M-4-13-iii
511
M-4-14-i
512
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2,789,266.14
2,872,944.13
2,928,729.45
2,984,514.77
6,131,943.65
6,315,901.96
6,438,540.83
6,561,179.71
3,806,676.39
3,920,876.68
3,997,010.21
4,073,143.74
4,261,598.05
4,389,445.99
4,474,677.95
4,559,909.91
11,323,908.48
11,663,625.74
11,890,103.91
12,116,582.08
3,065,971.83
3,157,950.98
3,219,270.42
3,280,589.85
M-4-14-ii
5,354,117.22
5,514,740.73
5,621,823.08
5,728,905.42
513
M-4-14-iii
OSTEOMIELITIS BERAT
6,948,971.95
7,157,441.11
7,296,420.55
7,435,399.99
514
M-4-15-i
2,572,963.38
2,650,152.28
2,701,611.55
2,753,070.82
515
M-4-15-ii
3,192,317.63
3,288,087.16
3,351,933.51
3,415,779.86
516
M-4-15-iii
7,177,064.61
7,392,376.55
7,535,917.84
7,679,459.14
517
M-4-16-i
2,570,477.76
2,647,592.10
2,699,001.65
2,750,411.21
518
M-4-16-ii
3,756,271.72
3,868,959.87
3,944,085.30
4,019,210.74
519
M-4-16-iii
7,668,368.39
7,898,419.45
8,051,786.81
8,205,154.18
520
M-4-17-i
2,202,231.89
2,268,298.85
2,312,343.49
2,356,388.13
521
M-4-17-ii
2,888,098.84
2,974,741.80
3,032,503.78
3,090,265.76
522
M-4-17-iii
3,962,652.47
4,081,532.05
4,160,785.10
4,240,038.15
523
M-4-18-i
3,021,263.85
3,111,901.77
3,172,327.04
3,232,752.32
524
M-4-18-ii
3,720,606.24
3,832,224.42
3,906,636.55
3,981,048.67
525
M-4-18-iii
5,123,887.14
5,277,603.76
5,380,081.50
5,482,559.24
526
M-4-19-i
2,246,350.56
2,313,741.07
2,358,668.08
2,403,595.10
527
M-4-19-ii
3,595,865.87
3,703,741.85
3,775,659.17
3,847,576.48
528
M-4-19-iii
5,737,915.38
5,910,052.84
6,024,811.15
6,139,569.46
529
M-4-20-i
1,674,676.61
1,724,916.91
1,758,410.44
1,791,903.97
530
M-4-20-ii
2,299,478.87
2,368,463.24
2,414,452.81
2,460,442.39
531
M-4-20-iii
2,548,364.55
2,624,815.48
2,675,782.77
2,726,750.07
532
M-4-21-i
1,604,752.01
1,652,894.57
1,684,989.61
1,717,084.65
533
M-4-21-ii
2,691,458.55
2,772,202.31
2,826,031.48
2,879,860.65
534
M-4-21-iii
5,557,073.93
5,723,786.15
5,834,927.63
5,946,069.11
535
N-1-01-i
4,189,605.25
4,315,293.41
4,399,085.51
4,482,877.62
536
N-1-01-ii
5,666,346.49
5,836,336.88
5,949,663.81
6,062,990.74

PELVIS SEDANG
PELVIS BERAT

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
RINGAN
SEDANG
BERAT
ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
- 677 No
Kode
INA-CBG
537
N-1-01-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
12,014,340.33
12,374,770.54
12,615,057.34
12,855,344.15
7,227,730.26
7,444,562.17
7,589,116.77
7,733,671.38
10,410,075.83
10,722,378.10
10,930,579.62
11,138,781.14
16,520,526.31
17,016,142.10
17,346,552.63
17,676,963.15
3,097,598.68
3,190,526.64
3,252,478.62
3,314,430.59
9,693,270.21
9,984,068.32
10,177,933.72
10,371,799.13
17,666,588.70
18,196,586.36
18,549,918.13
18,903,249.91
538
N-1-11-i
539
N-1-11-ii
540
N-1-11-iii
541
N-1-12-i
542
N-1-12-ii
543
N-1-12-iii
544
N-1-20-i
5,641,229.96
5,810,466.86
5,923,291.46
6,036,116.06
545
N-1-20-ii
11,184,553.41
11,520,090.01
11,743,781.08
11,967,472.14
546
N-1-20-iii
12,794,115.28
13,177,938.74
13,433,821.05
13,689,703.35
6,711,238.67
6,912,575.83
7,046,800.61
7,181,025.38
10,198,564.23
10,504,521.16
10,708,492.44
10,912,463.73
11,241,107.95
11,578,341.19
11,803,163.35
12,027,985.51
6,047,482.90
6,228,907.38
6,349,857.04
6,470,806.70
8,197,578.85
8,443,506.21
8,607,457.79
8,771,409.37
9,534,021.02
9,820,041.66
10,010,722.08
10,201,402.50
2,358,734.93
2,429,496.98
2,476,671.68
2,523,846.38
3,451,382.86
3,554,924.35
3,623,952.00
3,692,979.66
6,801,565.61
7,005,612.58
7,141,643.89
7,277,675.21


URIN BAWAH RINGAN
URIN BAWAH SEDANG
URIN BAWAH BERAT
RINGAN
SEDANG
BERAT
GINJAL RINGAN
GINJAL SEDANG
GINJAL BERAT
547
N-1-30-i
548
N-1-30-ii
549
N-1-30-iii
550
N-1-40-i
551
N-1-40-ii
552
N-1-40-iii
553
N-4-10-i
554
N-4-10-ii
555
N-4-10-iii
556
N-4-11-i
1,973,879.54
2,033,095.92
2,072,573.51
2,112,051.10
557
N-4-11-ii
3,335,808.87
3,435,883.14
3,502,599.32
3,569,315.49
558
N-4-11-iii
3,817,254.37
3,931,772.01
4,008,117.09
4,084,462.18
559
N-4-12-i
1,908,649.84
1,965,909.33
2,004,082.33
2,042,255.33
560
N-4-12-ii
2,682,555.55
2,763,032.21
2,816,683.33
2,870,334.44
561
N-4-12-iii
4,216,254.66
4,342,742.30
4,427,067.39
4,511,392.49
562
N-4-13-i
BATU URIN RINGAN
2,720,442.09
2,802,055.35
2,856,464.19
2,910,873.03
563
N-4-13-ii
BATU URIN SEDANG
3,279,830.15
3,378,225.06
3,443,821.66
3,509,418.26
564
N-4-13-iii
BATU URIN BERAT
8,077,321.85
8,319,641.51
8,481,187.95
8,642,734.38
565
N-4-14-i
1,341,218.56
1,381,455.12
1,408,279.49
1,435,103.86
566
N-4-14-ii
2,065,307.90
2,127,267.14
2,168,573.30
2,209,879.45

(RINGAN)
(SEDANG)
- 678 No
Kode
INA-CBG
567
N-4-14-iii
568
N-4-15-i
569
N-4-15-ii
570
N-4-15-iii
571
N-4-16-i
572
N-4-16-ii
573
N-4-16-iii
574
O-6-10-i
575
O-6-10-ii
576
O-6-10-iii
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
584
585
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3,349,271.07
3,449,749.20
3,516,734.62
3,583,720.04
2,649,809.75
2,729,304.05
2,782,300.24
2,835,296.44
3,636,363.37
3,745,454.27
3,818,181.54
3,890,908.80
4,149,746.90
4,274,239.31
4,357,234.24
4,440,229.18
2,661,252.19
2,741,089.76
2,794,314.80
2,847,539.84
3,434,280.99
3,537,309.42
3,605,995.04
3,674,680.66
6,849,634.48
7,055,123.52
7,192,116.21
7,329,108.90
3,310,105.15
3,409,408.30
3,475,610.40
3,541,812.51
3,674,721.29
3,784,962.93
3,858,457.36
3,931,951.78
4,528,501.45
4,664,356.49
4,754,926.52
4,845,496.55
2,089,713.33
2,152,404.73
2,194,199.00
2,235,993.27
3,404,755.99
3,506,898.67
3,574,993.79
3,643,088.91
5,770,004.80
5,943,104.95
6,058,505.05
6,173,905.14
2,311,058.78
2,380,390.54
2,426,611.71
2,472,832.89
2,775,575.84
2,858,843.11
2,914,354.63
2,969,866.15
3,487,113.30
3,591,726.70
3,661,468.97
3,731,211.23
1,637,665.99
1,686,795.97
1,719,549.29
1,752,302.61
O-6-13-ii
1,913,196.16
1,970,592.05
2,008,855.97
2,047,119.90
O-6-13-iii
2,379,312.72
2,450,692.10
2,498,278.35
2,545,864.61
38,905,347.43
40,072,507.85
40,850,614.80
41,628,721.75
48,139,281.66
49,583,460.11
50,546,245.75
51,509,031.38
56,502,021.91
58,197,082.56
59,327,123.00
60,457,163.44
62,771,924.81
64,655,082.56
65,910,521.05
67,165,959.55
72,005,859.05
74,166,034.82
75,606,152.00
77,046,269.18
82,271,842.41
84,739,997.68
86,385,434.53
88,030,871.38
2,581,332.24
2,658,772.20
2,710,398.85
2,762,025.49
3,844,798.88
3,960,142.84
4,037,038.82
4,113,934.80
6,987,448.45
7,197,071.90
7,336,820.87
7,476,569.84
586
P-8-01-i
587
P-8-01-ii
588
P-8-01-iii
589
P-8-02-i
590
P-8-02-ii
591
P-8-02-iii
592
P-8-03-i
593
P-8-03-ii
594
P-8-03-iii

(BERAT)
SALURAN URIN RINGAN
SALURAN URIN SEDANG
SALURAN URIN BERAT
RINGAN
SEDANG
BERAT
&KURET RINGAN
KURET SEDANG
KURET BERAT

- 679 No
Kode
INA-CBG
595
P-8-04-i
596
P-8-04-ii
597
P-8-04-iii
598
P-8-05-i
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii
603
P-8-06-iii
604
P-8-07-i
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
614
P-8-11-ii
615
P-8-11-iii
616
P-8-12-i
617
P-8-12-ii
618
P-8-12-iii
619
P-8-13-i
620
P-8-13-ii
621
P-8-13-iii
622
P-8-14-i
Deskripsi (INA-CBG)
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
RINGAN
SEDANG
BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
31,008,791.59
31,939,055.34
32,559,231.17
33,179,407.00
40,242,725.82
41,450,007.60
42,254,862.12
43,059,716.63
57,697,939.51
59,428,877.69
60,582,836.48
61,736,795.27
16,861,575.42
17,367,422.68
17,704,654.19
18,041,885.70
23,899,010.04
24,615,980.34
25,093,960.54
25,571,940.74
35,211,983.04
36,268,342.53
36,972,582.19
37,676,821.85
2,361,240.48
2,432,077.69
2,479,302.50
2,526,527.31
6,195,197.37
6,381,053.29
6,504,957.24
6,628,861.18
11,357,861.84
11,698,597.69
11,925,754.93
12,152,912.17
4,480,954.25
4,615,382.88
4,705,001.96
4,794,621.05
11,065,125.05
11,397,078.80
11,618,381.30
11,839,683.80
14,878,781.09
15,325,144.53
15,622,720.15
15,920,295.77
3,522,691.55
3,628,372.29
3,698,826.12
3,769,279.96
5,000,956.11
5,150,984.80
5,251,003.92
5,351,023.04
6,385,666.34
6,577,236.33
6,704,949.65
6,832,662.98
2,185,473.73
2,251,037.94
2,294,747.42
2,338,456.89
3,165,976.77
3,260,956.07
3,324,275.60
3,387,595.14
6,215,745.41
6,402,217.77
6,526,532.68
6,650,847.59
2,155,334.95
2,219,995.00
2,263,101.70
2,306,208.40
13,104,300.83
13,497,429.86
13,759,515.88
14,021,601.89
13,378,838.13
13,780,203.28
14,047,780.04
14,315,356.80
2,903,872.63
2,990,988.81
3,049,066.26
3,107,143.71
4,515,017.77
4,650,468.30
4,740,768.66
4,831,069.01
5,326,766.03
5,486,569.01
5,593,104.33
5,699,639.65
1,500,877.90
1,545,904.24
1,575,921.80
1,605,939.35
2,777,362.85
2,860,683.74
2,916,231.00
2,971,778.25
4,153,843.12
4,278,458.42
4,361,535.28
4,444,612.14
2,742,260.04
2,824,527.84
2,879,373.04
2,934,218.24
- 680 No
Kode
INA-CBG
623
P-8-14-ii
624
P-8-14-iii
625
P-8-15-i
626
P-8-15-ii
627
P-8-15-iii
628
P-8-16-i
629
P-8-16-ii
630
P-8-16-iii
631
P-8-17-i
632
P-8-17-ii
633
P-8-17-iii
634
S-4-10-i
635
S-4-10-ii
636
S-4-10-iii
637
S-4-11-i
638
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5,598,918.86
5,766,886.43
5,878,864.80
5,990,843.18
6,141,993.26
6,326,253.05
6,449,092.92
6,571,932.78
2,062,265.07
2,124,133.02
2,165,378.33
2,206,623.63
4,121,925.65
4,245,583.42
4,328,021.93
4,410,460.45
4,841,839.73
4,987,094.93
5,083,931.72
5,180,768.52
1,866,837.29
1,922,842.41
1,960,179.16
1,997,515.91
2,648,188.37
2,727,634.02
2,780,597.79
2,833,561.56
3,437,478.76
3,540,603.12
3,609,352.69
3,678,102.27
1,229,871.68
1,266,767.83
1,291,365.27
1,315,962.70
4,092,647.79
4,215,427.23
4,297,280.18
4,379,133.14
8,260,748.68
8,508,571.14
8,673,786.12
8,839,001.09
1,532,985.91
1,578,975.49
1,609,635.21
1,640,294.93
1,916,232.39
1,973,719.36
2,012,044.01
2,050,368.66
2,490,773.21
2,565,496.40
2,615,311.87
2,665,127.33
958,116.20
986,859.68
1,006,022.01
1,025,184.33
S-4-11-ii
1,532,985.91
1,578,975.49
1,609,635.21
1,640,294.93
639
S-4-11-iii
2,359,227.30
2,430,004.12
2,477,188.66
2,524,373.21
640
S-4-12-i
1,181,670.03
1,217,120.13
1,240,753.53
1,264,386.94
641
S-4-12-ii
1,616,220.49
1,664,707.10
1,697,031.51
1,729,355.92
642
S-4-12-iii
3,091,987.17
3,184,746.78
3,246,586.52
3,308,426.27
643
S-4-13-i
1,836,505.46
1,891,600.63
1,928,330.74
1,965,060.85
644
S-4-13-ii
3,025,344.65
3,116,104.99
3,176,611.88
3,237,118.78
645
S-4-13-iii
5,861,493.15
6,037,337.94
6,154,567.80
6,271,797.67
646
S-4-14-i
943,423.75
971,726.46
990,594.94
1,009,463.41
647
S-4-14-ii
2,004,148.48
2,064,272.93
2,104,355.90
2,144,438.87
648
S-4-14-iii
3,800,579.60
3,914,596.99
3,990,608.58
4,066,620.17
649
S-4-15-i
713,520.07
734,925.67
749,196.07
763,466.47
650
S-4-15-ii
1,346,655.42
1,387,055.09
1,413,988.19
1,440,921.30
651
S-4-15-iii
1,744,231.70
1,796,558.65
1,831,443.28
1,866,327.91
652
S-4-16-i
LUKA BAKAR RINGAN
2,929,170.96
3,017,046.09
3,075,629.51
3,134,212.93
653
S-4-16-ii
LUKA BAKAR SEDANG
5,096,434.08
5,249,327.10
5,351,255.78
5,453,184.47
654
S-4-16-iii
LUKA BAKAR BERAT
9,100,474.26
9,373,488.49
9,555,497.97
9,737,507.46

ASPIRASI RINGAN
ASPIRASI SEDANG
ASPIRASI BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT

PASIEN RINGAN
PASIEN SEDANG
PASIEN BERAT
- 681 No
Kode
INA-CBG
655
S-4-17-i
656
S-4-17-ii
657
S-4-17-iii
658
T-1-10-i
659
T-1-10-ii
660
T-1-10-iii
661
T-4-10-i
662
T-4-10-ii
663
T-4-10-iii
664
T-4-11-i
665
T-4-11-ii
666
T-4-11-iii
667
T-4-12-i
668
T-4-12-ii
669
T-4-12-iii
670
U-1-10-i
671
672
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1,924,144.29
1,981,868.62
2,020,351.51
2,058,834.39
2,240,864.25
2,308,090.18
2,352,907.47
2,397,724.75
3,461,594.62
3,565,442.46
3,634,674.35
3,703,906.25
1,986,248.01
2,045,835.45
2,085,560.41
2,125,285.37
2,667,396.32
2,747,418.21
2,800,766.14
2,854,114.07
4,852,863.36
4,998,449.26
5,095,506.53
5,192,563.79
652,432.84
672,005.83
685,054.48
698,103.14
1,243,392.34
1,280,694.11
1,305,561.95
1,330,429.80
1,807,554.94
1,861,781.59
1,897,932.69
1,934,083.78
859,234.51
885,011.55
902,196.24
919,380.93
1,352,190.57
1,392,756.28
1,419,800.09
1,446,843.91
2,177,980.71
2,243,320.13
2,286,879.75
2,330,439.36
1,414,088.52
1,456,511.18
1,484,792.95
1,513,074.72
2,107,028.67
2,170,239.53
2,212,380.10
2,254,520.67
3,244,873.71
3,342,219.93
3,407,117.40
3,472,014.87
1,442,132.23
1,485,396.20
1,514,238.84
1,543,081.49
U-1-10-ii
2,942,759.34
3,031,042.12
3,089,897.30
3,148,752.49
U-1-10-iii
12,707,429.42
13,088,652.30
13,342,800.89
13,596,949.48
6,195,197.37
6,381,053.29
6,504,957.24
6,628,861.18
8,260,263.16
8,508,071.05
8,673,276.31
8,838,481.58
18,667,299.63
19,227,318.62
19,600,664.62
19,974,010.61

DOKTER RINGAN
DOKTER SEDANG
DOKTER BERAT

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
673
U-1-11-i
674
U-1-11-ii
675
U-1-11-iii
676
U-1-12-i
5,092,492.86
5,245,267.65
5,347,117.50
5,448,967.36
677
U-1-12-ii
9,292,796.05
9,571,579.93
9,757,435.85
9,943,291.77
678
U-1-12-iii
12,066,871.58
12,428,877.72
12,670,215.15
12,911,552.59
679
U-1-13-i
4,130,131.58
4,254,035.53
4,336,638.16
4,419,240.79
680
U-1-13-ii
5,162,664.47
5,317,544.41
5,420,797.70
5,524,050.99
681
U-1-13-iii
8,985,618.78
9,255,187.35
9,434,899.72
9,614,612.10
3,065,322.34
3,157,282.01
3,218,588.45
3,279,894.90
3,761,766.99
3,874,620.00
3,949,855.34
4,025,090.68
4,457,799.74
4,591,533.73
4,680,689.73
4,769,845.72
1,800,380.73
1,854,392.15
1,890,399.76
1,926,407.38
682
U-1-14-i
683
U-1-14-ii
684
U-1-14-iii
685
U-1-15-i

- 682 No
Kode
INA-CBG
686
U-1-15-ii
687
U-1-15-iii
688
U-1-20-i
689
U-1-20-ii
690
U-1-20-iii
691
U-1-30-i
692
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2,558,215.27
2,634,961.73
2,686,126.03
2,737,290.34
5,041,066.03
5,192,298.01
5,293,119.34
5,393,940.66
4,656,800.75
4,796,504.77
4,889,640.79
4,982,776.80
7,320,324.13
7,539,933.85
7,686,340.34
7,832,746.82
15,202,951.50
15,659,040.05
15,963,099.08
16,267,158.11
3,994,722.92
4,114,564.61
4,194,459.06
4,274,353.52
U-1-30-ii
5,392,875.94
5,554,662.22
5,662,519.74
5,770,377.26
693
U-1-30-iii
8,260,263.16
8,508,071.05
8,673,276.31
8,838,481.58
694
U-4-10-i
3,718,419.78
3,829,972.38
3,904,340.77
3,978,709.17
695
U-4-10-ii
9,321,297.59
9,600,936.51
9,787,362.46
9,973,788.42
696
U-4-10-iii
13,597,743.30
14,005,675.60
14,277,630.47
14,549,585.34
697
U-4-11-i
1,725,638.26
1,777,407.41
1,811,920.17
1,846,432.94
698
U-4-11-ii
2,299,478.87
2,368,463.24
2,414,452.81
2,460,442.39
699
U-4-11-iii
4,277,654.11
4,405,983.73
4,491,536.81
4,577,089.89
700
U-4-12-i
1,532,985.91
1,578,975.49
1,609,635.21
1,640,294.93
701
U-4-12-ii
2,403,843.74
2,475,959.05
2,524,035.93
2,572,112.80
702
U-4-12-iii
3,822,002.33
3,936,662.40
4,013,102.45
4,089,542.49
703
U-4-13-i
1,532,985.91
1,578,975.49
1,609,635.21
1,640,294.93
704
U-4-13-ii
1,750,866.10
1,803,392.08
1,838,409.40
1,873,426.72
705
U-4-13-iii
2,674,036.92
2,754,258.02
2,807,738.76
2,861,219.50
706
U-4-14-i
1,916,232.39
1,973,719.36
2,012,044.01
2,050,368.66
707
U-4-14-ii
2,299,478.87
2,368,463.24
2,414,452.81
2,460,442.39
708
U-4-14-iii
3,876,443.54
3,992,736.84
4,070,265.71
4,147,794.58
1,651,240.37
1,700,777.58
1,733,802.38
1,766,827.19
2,174,616.48
2,239,854.97
2,283,347.30
2,326,839.63
2,949,351.68
3,037,832.23
3,096,819.26
3,155,806.29
5,093,698.48
5,246,509.43
5,348,383.40
5,450,257.37
5,781,795.47
5,955,249.34
6,070,885.25
6,186,521.15
9,809,062.50
10,103,334.37
10,299,515.62
10,495,696.87


DAN TELINGA RINGAN
DAN TELINGA SEDANG
DAN TELINGA BERAT


KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT
709
U-4-15-i
710
U-4-15-ii
711
U-4-15-iii
712
V-1-10-i
713
V-1-10-ii
714
V-1-10-iii
715
V-1-11-i
5,162,664.47
5,317,544.41
5,420,797.70
5,524,050.99
716
V-1-11-ii
5,761,620.11
5,934,468.71
6,049,701.11
6,164,933.51
717
V-1-11-iii
8,532,077.36
8,788,039.68
8,958,681.23
9,129,322.78
718
V-1-12-i

3,750,486.99
3,863,001.60
3,938,011.34
4,013,021.08
- 683 No
Kode
INA-CBG
719
V-1-12-ii
720
V-1-12-iii
721
V-1-13-i
722
V-1-13-ii
723
V-1-13-iii
724
V-1-14-i
725
V-1-14-ii
726
V-1-14-iii
727
V-1-15-i
728
V-1-15-ii
729
V-1-15-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
11,448,951.25
11,792,419.79
12,021,398.82
12,250,377.84
12,875,846.99
13,262,122.40
13,519,639.34
13,777,156.28
5,684,522.50
5,855,058.17
5,968,748.62
6,082,439.07
10,802,223.90
11,126,290.62
11,342,335.10
11,558,379.57
12,390,394.73
12,762,106.58
13,009,914.47
13,257,722.37
6,852,757.82
7,058,340.55
7,195,395.71
7,332,450.87
9,966,749.18
10,265,751.66
10,465,086.64
10,664,421.63
13,485,399.89
13,889,961.89
14,159,669.89
14,429,377.89
3,097,598.68
3,190,526.64
3,252,478.62
3,314,430.59
4,834,006.12
4,979,026.30
5,075,706.42
5,172,386.55
8,042,762.21
8,284,045.07
8,444,900.32
8,605,755.56
5,202,232.58
5,358,299.56
5,462,344.21
5,566,388.86
6,719,304.77
6,920,883.92
7,055,270.01
7,189,656.11
12,841,770.73
13,227,023.85
13,483,859.26
13,740,694.68
2,645,530.10
2,724,896.00
2,777,806.61
2,830,717.21
3,865,542.17
3,981,508.43
4,058,819.28
4,136,130.12
6,377,888.55
6,569,225.20
6,696,782.97
6,824,340.74
7,779,154.02
8,012,528.64
8,168,111.72
8,323,694.80
9,369,621.99
9,650,710.65
9,838,103.09
10,025,495.53
16,965,436.48
17,474,399.58
17,813,708.31
18,153,017.03

NON KOMPLEK (BERAT)

RINGAN
SEDANG
BERAT
730
V-4-10-i
731
V-4-10-ii
732
V-4-10-iii
733
V-4-11-i
734
V-4-11-ii
735
V-4-11-iii
736
W-1-01-i
737
W-1-01-ii
738
W-1-01-iii
739
W-1-10-i
2,065,065.79
2,127,017.76
2,168,319.08
2,209,620.39
740
W-1-10-ii
4,043,016.55
4,164,307.04
4,245,167.37
4,326,027.70
741
W-1-10-iii
6,613,092.33
6,811,485.10
6,943,746.95
7,076,008.79
742
W-1-11-i
2,250,257.42
2,317,765.14
2,362,770.29
2,407,775.44
743
W-1-11-ii
4,130,131.58
4,254,035.53
4,336,638.16
4,419,240.79
744
W-1-11-iii
6,195,197.37
6,381,053.29
6,504,957.24
6,628,861.18
745
W-1-12-i
2,044,697.11
2,106,038.03
2,146,931.97
2,187,825.91
746
W-1-12-ii
2,324,781.44
2,394,524.88
2,441,020.51
2,487,516.14
747
W-1-12-iii
3,571,157.38
3,678,292.10
3,749,715.25
3,821,138.39
748
W-1-13-i
1,827,500.24
1,882,325.24
1,918,875.25
1,955,425.25
749
W-1-13-ii
1,984,138.54
2,043,662.70
2,083,345.47
2,123,028.24
750
W-1-13-iii
2,665,064.24
2,745,016.17
2,798,317.45
2,851,618.74

SERVIK RINGAN
SERVIK SEDANG
SERVIK BERAT
ENDOSKOP RINGAN
ENDOSKOP SEDANG
ENDOSKOP BERAT
- 684 No
Kode
INA-CBG
751
W-1-20-i
752
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
6,631,065.04
6,829,996.99
6,962,618.29
7,095,239.59
W-1-20-ii
8,260,263.16
8,508,071.05
8,673,276.31
8,838,481.58
753
W-1-20-iii
9,292,796.05
9,571,579.93
9,757,435.85
9,943,291.77
754
W-1-30-i
3,619,896.61
3,728,493.51
3,800,891.44
3,873,289.38
755
W-1-30-ii
5,162,664.47
5,317,544.41
5,420,797.70
5,524,050.99
756
W-1-30-iii
15,354,280.28
15,814,908.69
16,121,994.29
16,429,079.90
757
W-4-10-i
2,699,535.97
2,780,522.05
2,834,512.77
2,888,503.49
758
W-4-10-ii
3,648,725.31
3,758,187.07
3,831,161.58
3,904,136.08
759
W-4-10-iii
6,558,995.35
6,755,765.21
6,886,945.12
7,018,125.03
760
W-4-11-i
1,916,232.39
1,973,719.36
2,012,044.01
2,050,368.66
761
W-4-11-ii
3,215,801.68
3,312,275.73
3,376,591.76
3,440,907.80
762
W-4-11-iii
3,882,540.00
3,999,016.20
4,076,667.00
4,154,317.80
763
W-4-12-i
1,532,985.91
1,578,975.49
1,609,635.21
1,640,294.93
764
W-4-12-ii
2,620,091.20
2,698,693.93
2,751,095.76
2,803,497.58
765
W-4-12-iii
3,161,023.98
3,255,854.70
3,319,075.18
3,382,295.66
766
W-4-13-i
ABORTUS RINGAN
840,707.56
865,928.79
882,742.94
899,557.09
767
W-4-13-ii
ABORTUS SEDANG
1,149,739.43
1,184,231.62
1,207,226.41
1,230,221.20
768
W-4-13-iii
ABORTUS BERAT
1,532,985.91
1,578,975.49
1,609,635.21
1,640,294.93
769
W-4-14-i
1,149,739.43
1,184,231.62
1,207,226.41
1,230,221.20
770
W-4-14-ii
1,532,985.91
1,578,975.49
1,609,635.21
1,640,294.93
771
W-4-14-iii
1,860,720.72
1,916,542.34
1,953,756.75
1,990,971.17
772
W-4-15-i
1,149,739.43
1,184,231.62
1,207,226.41
1,230,221.20
773
W-4-15-ii
1,235,683.73
1,272,754.24
1,297,467.92
1,322,181.59
774
W-4-15-iii
1,563,359.02
1,610,259.79
1,641,526.97
1,672,794.15
775
W-4-16-i
1,293,846.40
1,332,661.79
1,358,538.72
1,384,415.65
776
W-4-16-ii
2,049,851.65
2,111,347.20
2,152,344.23
2,193,341.27
777
W-4-16-iii
2,612,491.62
2,690,866.37
2,743,116.20
2,795,366.04
778
W-4-17-i
1,149,739.43
1,184,231.62
1,207,226.41
1,230,221.20
779
W-4-17-ii
1,532,985.91
1,578,975.49
1,609,635.21
1,640,294.93
780
W-4-17-iii
2,900,104.44
2,987,107.58
3,045,109.67
3,103,111.75
781
Z-4-10-i
REHABILITASI RINGAN
2,656,905.13
2,736,612.29
2,789,750.39
2,842,888.49
782
Z-4-10-ii
REHABILITASI SEDANG
3,526,658.02
3,632,457.76
3,702,990.92
3,773,524.08
783
Z-4-10-iii
REHABILITASI BERAT
5,009,954.13
5,160,252.75
5,260,451.83
5,360,650.91
784
Z-4-11-i
3,088,448.02
3,181,101.46
3,242,870.42
3,304,639.38

RINGAN
SEDANG
BERAT

- 685 No
Kode
INA-CBG
Deskripsi (INA-CBG)
785
Z-4-11-ii
786
Z-4-11-iii
787
Z-4-12-i
788
Z-4-12-ii
789
Z-4-12-iii
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3,717,808.87
3,829,343.14
3,903,699.32
3,978,055.49
5,812,282.55
5,986,651.03
6,102,896.68
6,219,142.33
1,194,536.86
1,230,372.96
1,254,263.70
1,278,154.44
3,150,977.79
3,245,507.13
3,308,526.68
3,371,546.24
4,004,393.87
4,124,525.68
4,204,613.56
4,284,701.44

- 686 b. RawatJalan
No
Kode
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
775,006
798,256
813,756
829,256
1,005,304
1,035,463
1,055,569
1,075,675
1,869,494
1,925,579
1,962,969
2,000,359
1,544,956
1,591,304
1,622,204
1,653,103
1,290,677
1,329,398
1,355,211
1,381,025
452,517
466,093
475,143
484,193
1,009,054
1,039,326
1,059,507
1,079,688

207,327
213,547
217,694
221,840
C-3-10-0
565,560
582,527
593,838
605,149
10
C-3-11-0

KANDUNG KEMIH
894,454
921,288
939,177
957,066
11
C-3-12-0
202,771
208,854
212,909
216,965
196,904
202,812
206,750
210,688
1,676,251
1,726,538
1,760,063
1,793,588
1,536,351
1,582,441
1,613,168
1,643,895

LAPAROSKOPI
PANKREAS
LAPAROSKOPI
EMPEDU

OVARIUM
GASTROINTESTINAL
GINJAL ATAU PROSTAT
12
C-3-13-0
13
C-3-14-0
14
C-3-15-0
15
C-3-16-0
348,407
358,860
365,828
372,796
16
C-3-17-0

LEHER
231,123
238,057
242,679
247,302
17
C-3-18-0
102,470
105,544
107,594
109,643
18
C-3-19-0

MYELOMA ATAU TESTIS
144,913
149,261
152,159
155,057
19
C-3-20-0
2,885,957
2,972,536
3,030,255
3,087,974
20
C-3-21-0
165,372
170,333
173,641
176,948
21
C-3-22-0
726,072
747,854
762,376
776,897
22
C-3-23-0
117,608
121,136
123,488
125,840
23
D-2-10-0

TULANG
996,390
1,026,282
1,046,209
1,066,137
24
D-2-11-0
PROSEDUR LIMPA
1,247,650
1,285,080
1,310,033
1,334,986
25
D-2-21-0
1,046,425
1,077,818
1,098,747
1,119,675
26
D-2-22-0
229,659
236,549
241,142
245,735
27
D-3-10-0
166,348
171,338
174,665
177,992
28
D-3-11-0
431,886
444,843
453,481
462,118
29
E-2-10-0
256,192
263,877
269,001
274,125
30
E-2-21-0
185,730
191,302
195,017
198,731
31
E-2-22-0
185,730
191,302
195,017
198,731

TYMUS
TYMUS
TULANG
PEMBENTUK DARAH
PARATIROID
THYROGLOSSAL
- 687 No
Kode
INA-CBG
32
E-3-10-0
33
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

ENDOKRIN
215,992
222,472
226,792
231,112
F-3-10-0
TERAPI SHOCK
301,302
310,341
316,367
322,393
34
F-5-10-0
369,193
380,268
387,652
395,036
35
F-5-11-0
TERAPI KELOMPOK
243,449
250,752
255,621
260,490
36
F-5-12-0
311,534
320,880
327,110
333,341
37
F-5-13-0
263,848
271,764
277,041
282,318
38
F-5-14-0
177,007
182,317
185,857
189,397
39
F-5-15-0
166,055
171,037
174,358
177,679
40
F-5-16-0
172,963
178,151
181,611
185,070
41
G-2-10-0
145,648
150,017
152,930
155,843
42
G-2-11-0
1,262,536
1,300,412
1,325,663
1,350,914
43
G-2-12-0

EKSTRAKRANIAL
1,829,726
1,884,618
1,921,212
1,957,807
44
G-2-13-0
448,873
462,339
471,316
480,294
45
G-2-21-0
818,668
843,228
859,601
875,975
46
G-2-22-0
743,011
765,301
780,161
795,022
47
G-2-31-0
1,226,033
1,262,814
1,287,334
1,311,855
48
G-2-32-0
628,463
647,317
659,886
672,456
49
G-3-10-0
249,441
256,924
261,913
266,902
50
G-3-11-0
332,208
342,174
348,818
355,462
51
G-3-12-0
544,328
560,658
571,544
582,431
52
G-3-13-0
544,390
560,722
571,610
582,497
53
H-2-21-0
714,431
735,864
750,153
764,441
54
H-2-22-0
185,730
191,302
195,017
198,731
55
H-2-23-0
185,730
191,302
195,017
198,731
56
H-2-31-0
1,183,396
1,218,898
1,242,565
1,266,233
57
H-2-32-0
123,164
126,859
129,322
131,785
58
H-2-33-0
185,730
191,302
195,017
198,731
59
H-2-34-0
530,900
546,827
557,445
568,063
60
H-2-35-0
174,944
180,192
183,691
187,190
61
H-2-36-0
944,305
972,634
991,520
1,010,406
62
H-2-37-0

1,005,254
1,035,412
1,055,517
1,075,622
63
H-3-10-0
349,755
360,248
367,243
374,238
64
H-3-11-0
183,932
189,450
193,129
196,808

AKUT
MENTAL
PROSEDUR KRANIOTOMI

MATA
MATA
MATA
MATA
MATA
- 688 No
Kode
INA-CBG
65
H-3-12-0
66
H-3-13-0
67
I-2-11-0
68
I-2-12-0
69
I-2-13-0
70
I-2-14-0
71
I-2-15-0
Deskripsi (INA-CBG)
MATA
TORASIK
ABDOMEN
PENGGANTIAN ALAT
DARAH VENA
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
192,035
197,796
201,636
205,477
186,454
192,048
195,777
199,506
2,150,214
2,214,720
2,257,725
2,300,729
1,511,835
1,557,190
1,587,427
1,617,663
1,921,451
1,979,095
2,017,524
2,055,953
3,400,560
3,502,576
3,570,588
3,638,599
204,503
210,638
214,728
218,818
2,147,884
2,212,320
2,255,278
2,298,235
708,096
729,338
743,500
757,662
72
I-2-16-0
73
I-2-17-0
74
I-2-21-0
1,657,861
1,707,597
1,740,754
1,773,911
75
I-2-22-0
1,561,166
1,608,001
1,639,225
1,670,448
76
I-2-23-0
319,488
329,073
335,462
341,852
77
I-2-31-0
2,484,766
2,559,309
2,609,004
2,658,700
78
I-2-32-0
3,249,197
3,346,672
3,411,656
3,476,640
79
I-2-41-0
2,178,626
2,243,985
2,287,558
2,331,130
80
I-2-42-0

LAIN
2,533,013
2,609,004
2,659,664
2,710,324
81
I-3-10-0
PROSEDUR RESUSITASI
321,544
331,190
337,621
344,052
82
I-3-11-0
169,710
174,801
178,195
181,590
83
I-3-12-0
986,290
1,015,879
1,035,605
1,055,331
84
I-3-13-0
323,936
333,654
340,133
346,611
85
I-3-14-0
207,632
213,861
218,013
222,166
183,932
189,450
193,129
196,808
1,138,791
1,172,955
1,195,730
1,218,506
183,573
189,080
192,752
196,423
925,093
952,845
971,347
989,849
1,199,928
1,235,926
1,259,924
1,283,923

PACU JANTUNG

KARDIOVASKULAR
PERNAFASAN
PENDEK
86
I-3-15-0
87
J-2-10-0
88
J-2-21-0
89
J-2-22-0
90
J-2-31-0
PROSEDUR
91
J-2-32-0
892,945
919,734
937,593
955,452
92
J-3-10-0
185,730
191,302
195,017
198,731
93
J-3-11-0

PADA DADA
524,840
540,586
551,082
561,579
94
J-3-12-0
202,771
208,854
212,909
216,965
95
J-3-13-0
298,428
307,381
313,350
319,318
96
J-3-14-0
316,814
326,318
332,655
338,991
- 689 No
Kode
INA-CBG
97
J-3-15-0
98
J-3-16-0
99
J-3-17-0
100
K-2-10-0
101
K-2-11-0
102
K-2-12-0

103
K-2-13-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
277,821
286,155
291,712
297,268
316,814
326,318
332,655
338,991
185,730
191,302
195,017
198,731
534,595
550,633
561,325
572,017
1,141,578
1,175,826
1,198,657
1,221,489
876,309
902,598
920,124
937,650
1,426,240
1,469,027
1,497,552
1,526,077
185,730
191,302
195,017
198,731
185,730
191,302
195,017
198,731
2,387,075
2,458,687
2,506,429
2,554,170
802,652
826,732
842,785
858,838
185,730
191,302
195,017
198,731

PERNAFASAN
KECIL

FEMORALIS
USUS BESAR
ATAS
ATAS
104
K-2-14-0
105
K-2-21-0
106
K-2-22-0
107
K-2-31-0
108
K-2-32-0
109
K-2-41-0
884,138
910,662
928,345
946,027
110
K-2-42-0

252,609
260,187
265,240
270,292
111
K-2-51-0
585,883
603,460
615,177
626,895
112
K-2-52-0
319,488
329,073
335,462
341,852
113
K-2-53-0
185,730
191,302
195,017
198,731
114
K-3-10-0

GASTROINTESTINAL
353,432
364,035
371,104
378,172
115
K-3-11-0
212,482
218,856
223,106
227,355
116
K-3-12-0
215,483
221,948
226,257
230,567
117
K-3-13-0
185,730
191,302
195,017
198,731
497,761
512,694
522,649
532,604
240,376
247,587
252,394
257,202
318,513
328,068
334,439
340,809
1,095,060
1,127,911
1,149,813
1,171,714
701,925
722,983
737,022
751,060
316,814
326,318
332,655
338,991
319,488
329,073
335,462
341,852

GASTROINTESTINAL
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
118
K-3-14-0
119
K-3-15-0
120
K-3-16-0
121
L-2-21-0
122
L-2-22-0
123
L-2-31-0
124
L-2-32-0
125
L-2-41-0
956,669
985,369
1,004,502
1,023,636
126
L-2-42-0

214,565
221,002
225,294
229,585
127
L-2-51-0
1,432,283
1,475,252
1,503,897
1,532,543
L-2-52-0

1,095,744
1,128,616
1,150,531
1,172,446
128
- 690 No
Kode
INA-CBG
129
L-2-53-0
130
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

185,730
191,302
195,017
198,731
L-3-10-0
252,609
260,187
265,240
270,292
131
L-3-11-0
245,301
252,660
257,566
262,472
132
L-3-12-0
186,820
192,425
196,161
199,897
133
M-2-10-0
1,465,330
1,509,290
1,538,597
1,567,903
134
M-2-21-0
1,312,305
1,351,674
1,377,920
1,404,166
135
M-2-22-0
319,488
329,073
335,462
341,852
136
M-2-31-0
PROSEDUR BUNION
797,093
821,006
836,948
852,890
137
M-2-32-0
252,609
260,187
265,240
270,292
138
M-2-41-0

TULANG
252,609
260,187
265,240
270,292
139
M-2-42-0
87,056
89,668
91,409
93,150
140
M-2-51-0
185,730
191,302
195,017
198,731
141
M-2-52-0
185,730
191,302
195,017
198,731
142
M-2-61-0
PROSEDUR ARTROSKOPI
910,361
937,672
955,879
974,086
143
M-2-62-0
185,730
191,302
195,017
198,731
915,285
942,744
961,050
979,355
1,248,260
1,285,708
1,310,673
1,335,639
185,730
191,302
195,017
198,731
921,544
949,191
967,621
986,052
889,329
916,009
933,796
951,583

DAN WAJAH
PAHA
PAHA

TULANG
WAJAH
WAJAH
BAWAH
BAWAH
144
M-2-63-0
145
M-2-64-0
146
M-2-65-0
147
M-2-71-0
148
M-2-72-0
149
M-2-81-0
1,326,180
1,365,965
1,392,489
1,419,012
150
M-2-82-0
963,384
992,286
1,011,554
1,030,821
151
M-2-83-0
185,730
191,302
195,017
198,731
152
M-2-84-0
185,730
191,302
195,017
198,731
153
M-3-10-0
530,110
546,013
556,615
567,217
154
M-3-11-0
293,914
302,731
308,609
314,487
155
M-3-12-0
664,663
684,603
697,896
711,189
156
M-3-13-0
216,698
223,199
227,533
231,867
157
M-3-14-0

TERTUTUP
370,374
381,485
388,892
396,300
158
M-3-15-0
163,172
168,067
171,331
174,594
159
M-3-16-0

185,730
191,302
195,017
198,731
160
M-3-17-0
202,771
208,854
212,909
216,965
161
N-2-11-0
2,453,678
2,527,288
2,576,362
2,625,435

PERGELANGAN TANGAN
PERGELANGAN TANGAN
MUSKULOSKELETAL
SKELETAL
- 691 No
Kode
INA-CBG
162
N-2-12-0
163
N-2-21-0
164
N-2-22-0
165
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1,419,428
1,462,011
1,490,400
1,518,788
1,411,946
1,454,305
1,482,544
1,510,783
319,488
329,073
335,462
341,852
N-2-23-0
319,488
329,073
335,462
341,852
166
N-2-24-0
1,032,478
1,063,452
1,084,102
1,104,751
167
N-2-31-0
869,179
895,254
912,638
930,022
168
N-2-32-0
319,488
329,073
335,462
341,852
169
N-2-41-0
319,488
329,073
335,462
341,852
170
N-2-42-0
540,315
556,525
567,331
578,138
171
N-3-10-0
319,488
329,073
335,462
341,852
172
N-3-11-0
370,172
381,278
388,681
396,085
173
N-3-12-0
286,049
294,630
300,351
306,072
174
N-3-13-0
319,488
329,073
335,462
341,852
175
N-3-14-0
274,902
283,149
288,647
294,145
176
N-3-15-0
704,918
726,066
740,164
754,262
177
O-7-10-0
117,691
121,222
123,575
125,929
178
O-7-11-0
648,155
667,600
680,563
693,526
179
O-7-12-0
236,015
243,096
247,816
252,536
180
O-7-13-0
131,167
135,102
137,725
140,348
181
P-9-10-0
174,944
180,192
183,691
187,190
182
P-9-11-0
174,944
180,192
183,691
187,190
183
P-9-12-0
174,944
180,192
183,691
187,190
184
P-9-13-0
174,944
180,192
183,691
187,190
185
P-9-14-0
174,944
180,192
183,691
187,190
186
P-9-15-0
111,513
114,858
117,088
119,319
187
P-9-16-0
174,944
180,192
183,691
187,190
188
P-9-17-0
174,191
179,417
182,901
186,385
189
Q-5-10-0
228,007
234,848
239,408
243,968
190
Q-5-11-0
170,885
176,012
179,430
182,847
191
Q-5-12-0
GIGI
150,614
155,132
158,144
161,157
192
Q-5-13-0
MEDICAL CHECK-UP
114,460
117,894
120,183
122,472
193
Q-5-14-0
125,943
129,722
132,240
134,759


DAN URETHRA
DAN URETHRA
TRANSURETHRA
TRANSURETHRA
SALURAN KEMIH
KEMIH
KEMIH
PROSEDUR DIALISIS
CAESAR
VAGINAL/JALAN LAHIR

ASPIRASI
- 692 No
Kode
INA-CBG
194
Q-5-15-0
195
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
86,611
89,209
90,942
92,674
Q-5-16-0
VAKSINASI
97,891
100,827
102,785
104,743
196
Q-5-17-0
PASANG INFUS
84,673
87,213
88,906
90,600
197
Q-5-18-0
159,381
164,162
167,350
170,537
198
Q-5-19-0
178,178
183,523
187,087
190,651
199
Q-5-20-0
ABORSI MENGANCAM
119,427
123,010
125,398
127,787
200
Q-5-21-0
ABORSI
117,800
121,334
123,690
126,046
201
Q-5-22-0
125,943
129,722
132,240
134,759
202
Q-5-23-0
154,188
158,813
161,897
164,981
203
Q-5-24-0
105,308
108,467
110,573
112,680
204
Q-5-25-0
164,226
169,153
172,437
175,722
205
Q-5-26-0
BRONKIAL AKUT
232,450
239,424
244,073
248,722
206
Q-5-27-0
165,423
170,386
173,694
177,003
207
Q-5-28-0
134,236
138,264
140,948
143,633
208
Q-5-29-0

JANTUNG LAIN-LAIN
380,046
391,447
399,048
406,649
209
Q-5-30-0
440,432
453,645
462,453
471,262
210
Q-5-31-0
FRAKTUR
157,128
161,842
164,985
168,127
211
Q-5-32-0
SALURAN KEMIH AKUT
181,990
187,450
191,090
194,729
212
Q-5-33-0
HEMATOLOGI AKUT
190,543
196,259
200,070
203,881
213
Q-5-34-0
INFEKSI VIRUS HIV
270,680
278,800
284,214
289,627
214
Q-5-35-0
INFEKSI AKUT
306,943
316,152
322,291
328,430
215
Q-5-36-0
357,456
368,179
375,328
382,477
216
Q-5-37-0

SHOCK
182,321
187,790
191,437
195,083
217
Q-5-38-0
PARU AKUT
243,130
250,424
255,287
260,150
218
Q-5-39-0
155,586
160,253
163,365
166,477
219
Q-5-40-0
152,654
157,234
160,287
163,340
220
Q-5-41-0
211,328
217,668
221,895
226,121
221
Q-5-42-0
165,690
170,660
173,974
177,288
222
Q-5-43-0
238,603
245,761
250,533
255,305
223
Q-5-44-0
194,733
200,575
204,470
208,364
224
T-2-10-0

TERAPI DETOKSIKASI
1,476,229
1,520,515
1,550,040
1,579,565
225
U-2-10-0
1,348,022
1,388,463
1,415,423
1,442,384
226
U-2-11-0

LEHER
1,602,274
1,650,343
1,682,388
1,714,434
227
U-2-12-0
176,292
181,581
185,107
188,632
- 693 No
Kode
INA-CBG
228
U-2-13-0
229
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
231,123
238,057
242,679
247,302
U-2-14-0
429,322
442,202
450,788
459,375
230
U-2-15-0
243,931
251,249
256,128
261,007
231
U-2-21-0
284,142
292,666
298,349
304,032
232
U-2-22-0
548,985
565,455
576,434
587,414
233
U-2-23-0
719,348
740,928
755,315
769,702
234
U-2-24-0
606,254
624,442
636,567
648,692
235
U-2-25-0
231,123
238,057
242,679
247,302
236
U-2-31-0
185,730
191,302
195,017
198,731
237
U-2-32-0
231,123
238,057
242,679
247,302
238
U-3-10-0
220,966
227,595
232,014
236,434
239
U-3-11-0
234,597
241,635
246,327
251,019
240
U-3-12-0
103,738
106,851
108,925
111,000
241
U-3-13-0
228,025
234,866
239,427
243,987
242
U-3-14-0
209,508
215,793
219,984
224,174
243
U-3-15-0
182,710
188,191
191,845
195,499
244
U-3-16-0
PROSEDUR PADA GIGI
206,063
212,245
216,367
220,488
245
V-2-10-0

PROSTAT
2,010,387
2,070,699
2,110,907
2,151,114
246
V-2-11-0
226,721
233,522
238,057
242,591
723,497
745,202
759,672
774,142
319,488
329,073
335,462
341,852
319,488
329,073
335,462
341,852

(RHINOPLASTY)

RONGGA HIDUNG
TENGGOROKAN
PROSEDUR PADA PENIS

SKROTUM
SKROTUM
TRANSURETHRAL
247
V-2-12-0
248
V-2-13-0
249
V-2-14-0
250
V-2-15-0
SIRKUMSISI/SUNAT
174,944
180,192
183,691
187,190
251
V-3-10-0
364,857
375,802
383,100
390,397
252
V-3-11-0
771,861
795,017
810,454
825,891
253
V-3-12-0
445,616
458,984
467,897
476,809
254
W-2-10-0
163,172
168,067
171,331
174,594
255
W-2-11-0
417,007
429,518
437,858
446,198
256
W-2-12-0
771,861
795,017
810,454
825,891
257
W-2-13-0
123,793
127,507
129,982
132,458
258
W-2-21-0
1,551,647
1,598,196
1,629,229
1,660,262
259
W-2-22-0
163,172
168,067
171,331
174,594

PROSEDUR ABORSI
RAHIM & LEHER RAHIM
TERHALANG/TERGANGGU
TERHALANG/TERGANGGU
PANGGUL TERBUKA
PANGGUL TERBUKA
- 694 No
Kode
INA-CBG
260
W-2-23-0
Deskripsi (INA-CBG)
JALAN LAHIR
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
544,514
560,849
571,739
582,630
1,787,473
1,841,097
1,876,846
1,912,596
1,253,636
1,291,245
1,316,317
1,341,390
261
W-2-31-0
262
W-2-32-0
263
W-2-33-0
532,812
548,796
559,452
570,109
264
W-2-34-0
181,219
186,655
190,280
193,904
265
W-3-10-0
440,431
453,644
462,453
471,262
266
W-3-11-0
352,068
362,630
369,672
376,713
267
W-3-12-0
163,172
168,067
171,331
174,594
268
Z-3-10-0
1,847,327
1,902,747
1,939,693
1,976,640
269
Z-3-11-0

EMPEDU
1,411,946
1,454,305
1,482,544
1,510,783
270
Z-3-12-0
235,761
242,834
247,549
252,264
271
Z-3-13-0

LAIN-LAIN
1,438,678
1,481,838
1,510,611
1,539,385
272
Z-3-14-0
DIAGNOSTIK TIDUR
284,471
293,005
298,695
304,384
273
Z-3-15-0
185,730
191,302
195,017
198,731
274
Z-3-16-0

(MRI)
596,137
614,022
625,944
637,867
275
Z-3-17-0
PENGOBATAN NUKLIR
250,271
257,780
262,785
267,790
276
Z-3-18-0
CT-SCAN KEPALA
241,132
248,366
253,188
258,011
277
Z-3-19-0
CT SCAN LAIN-LAIN
250,971
258,500
263,520
268,539
278
Z-3-20-0
170,692
175,812
179,226
182,640
279
Z-3-21-0
163,172
168,067
171,331
174,594
280
Z-3-22-0
183,962
189,481
193,160
196,839
281
Z-3-23-0
191,612
197,361
201,193
205,025
282
Z-3-24-0
376,480
387,775
395,304
402,834
283
Z-3-25-0
167,684
172,714
176,068
179,422
284
Z-3-26-0
189,516
195,201
198,992
202,782
285
Z-3-27-0
PERAWATAN LUKA
180,936
186,364
189,983
193,602
286
Z-3-28-0
IMAGING PAYUDARA
185,730
191,302
195,017
198,731
287
Z-3-29-0
IMAGING LAIN-LAIN
535,308
551,367
562,073
572,779
288
Z-3-30-0
FOTOTERAPI
90,340
93,050
94,857
96,664
- 695 2. RUMAH SAKIT KUSTAKELAS C

a. RawatInap
No
Kode
INA-CBG
A-4-10-i
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
SEPTIKEMIA RINGAN
2.174.376
2.239.607
2.283.095
2.326.582
A-4-10-ii
SEPTIKEMIA SEDANG
2.489.076
2.563.749
2.613.530
2.663.312
A-4-10-iii
SEPTIKEMIA BERAT
3.902.402
4.019.474
4.097.522
4.175.570
A-4-11-i
3.907.861
4.025.097
4.103.254
4.181.412
A-4-11-ii

SEDANG
6.037.194
6.218.310
6.339.054
6.459.798
A-4-11-iii
9.875.531
10.171.797
10.369.307
10.566.818
A-4-12-i
DEMAM RINGAN
1.532.986
1.578.975
1.609.635
1.640.295
A-4-12-ii
DEMAM SEDANG
2.198.736
2.264.699
2.308.673
2.352.648
A-4-12-iii
DEMAM BERAT
2.516.293
2.591.781
2.642.107
2.692.433
10
A-4-13-i
1.916.232
1.973.719
2.012.044
2.050.369
11
A-4-13-ii
2.299.479
2.368.463
2.414.453
2.460.442
12
A-4-13-iii
2.794.745
2.878.587
2.934.482
2.990.377
13
A-4-14-i
104.888
108.035
110.133
112.230
14
A-4-14-ii
134.972
139.021
141.721
144.420
15
A-4-14-iii
154.219
158.846
161.930
165.014
16
A-4-15-i
INFEKSI HIV RINGAN
2.299.479
2.368.463
2.414.453
2.460.442
17
A-4-15-ii
INFEKSI HIV SEDANG
3.449.218
3.552.695
3.621.679
3.690.664
18
A-4-15-iii
INFEKSI HIV BERAT
4.797.050
4.940.962
5.036.903
5.132.844
19
B-1-01-i
25.493.308
26.258.107
26.767.974
27.277.840
20
B-1-01-ii
28.125.935
28.969.713
29.532.231
30.094.750
21
B-1-01-iii
49.338.677
50.818.837
51.805.611
52.792.384
22
B-1-10-i
3.305.121
3.404.275
3.470.377
3.536.479
23
B-1-10-ii
8.423.040
8.675.731
8.844.192
9.012.653
24
B-1-10-iii
14.661.180
15.101.015
15.394.239
15.687.463
25
B-1-11-i
2.259.482
2.327.266
2.372.456
2.417.646
26
B-1-11-ii
5.671.513
5.841.658
5.955.088
6.068.519
27
B-1-11-iii
7.110.670
7.323.990
7.466.203
7.608.416
28
B-1-12-i
4.819.556
4.964.143
5.060.534
5.156.925
29
B-1-12-ii
10.329.488
10.639.373
10.845.963
11.052.553
30
B-1-12-iii
12.571.377
12.948.518
13.199.945
13.451.373

LAIN-LAIN RINGAN
LAIN-LAIN SEDANG
LAIN-LAIN BERAT

(RINGAN)
(SEDANG)
(BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT
- 696 No
Kode
INA-CBG
31
B-1-13-i
32
B-1-13-ii
33
B-1-13-iii
34
B-1-14-i
35
B-1-14-ii
36
B-1-14-iii
37
B-4-10-i
38
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.158.148
3.252.892
3.316.055
3.379.218
5.144.165
5.298.490
5.401.373
5.504.256
7.583.942
7.811.461
7.963.140
8.114.818
4.288.543
4.417.199
4.502.970
4.588.741
4.769.725
4.912.817
5.008.211
5.103.606
7.461.668
7.685.518
7.834.751
7.983.985
1.199.364
1.235.345
1.259.332
1.283.320
B-4-10-ii
1.916.232
1.973.719
2.012.044
2.050.369
39
B-4-10-iii
2.929.692
3.017.583
3.076.176
3.134.770
40
B-4-11-i
2.896.934
2.983.842
3.041.780
3.099.719
41
B-4-11-ii
4.404.062
4.536.184
4.624.266
4.712.347
42
B-4-11-iii
4.743.328
4.885.628
4.980.495
5.075.361
43
B-4-12-i
2.541.861
2.618.117
2.668.954
2.719.791
44
B-4-12-ii
3.603.733
3.711.845
3.783.920
3.855.994
45
B-4-12-iii
7.004.179
7.214.304
7.354.388
7.494.471
46
B-4-13-i
2.299.479
2.368.463
2.414.453
2.460.442
47
B-4-13-ii
3.588.463
3.696.117
3.767.886
3.839.655
48
B-4-13-iii
5.446.525
5.609.921
5.718.852
5.827.782
49
B-4-14-i
2.299.479
2.368.463
2.414.453
2.460.442
50
B-4-14-ii
2.682.725
2.763.207
2.816.862
2.870.516
51
B-4-14-iii
3.579.026
3.686.396
3.757.977
3.829.557
52
C-4-10-i
2.239.228
2.306.405
2.351.190
2.395.974
53
C-4-10-ii
4.350.586
4.481.103
4.568.115
4.655.127
54
C-4-10-iii
LEUKEMIA AKUT BERAT
7.281.683
7.500.134
7.645.767
7.791.401
55
C-4-11-i
2.299.479
2.368.463
2.414.453
2.460.442
56
C-4-11-ii
3.065.972
3.157.951
3.219.270
3.280.590
57
C-4-11-iii
5.212.511
5.368.886
5.473.137
5.577.387
58
C-4-12-i
RADIOTERAPI RINGAN
1.532.986
1.578.975
1.609.635
1.640.295
59
C-4-12-ii
RADIOTERAPI SEDANG
4.220.773
4.347.396
4.431.812
4.516.227
60
C-4-12-iii
RADIOTERAPI BERAT
8.569.015
8.826.086
8.997.466
9.168.846
61
C-4-13-i
KEMOTERAPI RINGAN
1.532.986
1.578.975
1.609.635
1.640.295
62
C-4-13-ii
KEMOTERAPI SEDANG
3.065.972
3.157.951
3.219.270
3.280.590
63
C-4-13-iii
KEMOTERAPI BERAT
4.011.597
4.131.945
4.212.177
4.292.409

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT

PANCREAS RINGAN
PANCREAS SEDANG
PANCREAS BERAT
(RINGAN)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT
- 697 No
Kode
INA-CBG
64
C-4-14-i
65
C-4-14-ii
66
C-4-14-iii
67
D-1-10-i
68
D-1-10-ii
69
D-1-10-iii
70
D-1-11-i
71
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.987.873
2.047.509
2.087.266
2.127.024
2.904.806
2.991.951
3.050.047
3.108.143
4.428.293
4.561.142
4.649.708
4.738.274
16.312.788
16.802.172
17.128.428
17.454.683
24.845.628
25.590.997
26.087.909
26.584.822
33.672.615
34.682.793
35.356.245
36.029.698
3.352.953
3.453.542
3.520.601
3.587.660
D-1-11-ii
8.745.118
9.007.471
9.182.374
9.357.276
72
D-1-11-iii
12.390.395
12.762.107
13.009.914
13.257.722
73
D-1-20-i
4.130.132
4.254.036
4.336.638
4.419.241
74
D-1-20-ii
9.292.796
9.571.580
9.757.436
9.943.292
75
D-1-20-iii
16.798.267
17.302.215
17.638.181
17.974.146
76
D-4-10-i
1.472.527
1.516.703
1.546.153
1.575.604
77
D-4-10-ii
2.973.309
3.062.509
3.121.975
3.181.441
78
D-4-10-iii
3.832.465
3.947.439
4.024.088
4.100.737
79
D-4-11-i
3.353.407
3.454.009
3.521.077
3.588.145
80
D-4-11-ii
5.993.440
6.173.243
6.293.112
6.412.981
81
D-4-11-iii
8.205.378
8.451.540
8.615.647
8.779.755
82
D-4-12-i
1.965.689
2.024.660
2.063.973
2.103.287
83
D-4-12-ii
2.726.604
2.808.402
2.862.934
2.917.466
84
D-4-12-iii
4.186.701
4.312.302
4.396.036
4.479.770
85
D-4-13-i
1.532.986
1.578.975
1.609.635
1.640.295
86
D-4-13-ii
2.299.479
2.368.463
2.414.453
2.460.442
87
D-4-13-iii
2.682.725
2.763.207
2.816.862
2.870.516
88
D-4-14-i
1.847.061
1.902.473
1.939.414
1.976.355
89
D-4-14-ii
4.312.436
4.441.809
4.528.058
4.614.306
90
D-4-14-iii
5.144.139
5.298.463
5.401.346
5.504.229
91
E-1-01-i
3.674.729
3.784.971
3.858.466
3.931.960
92
E-1-01-ii
4.813.546
4.957.952
5.054.223
5.150.494
93
E-1-01-iii
10.910.013
11.237.313
11.455.514
11.673.714
94
E-1-10-i
3.744.352
3.856.683
3.931.570
4.006.457
95
E-1-10-ii
4.544.765
4.681.108
4.772.003
4.862.898
96
E-1-10-iii
9.579.026
9.866.397
10.057.978
10.249.558

RINGAN
SEDANG
BERAT
TULANG RINGAN
TULANG SEDANG
TULANG BERAT


RINGAN
SEDANG
BERAT
- 698 No
Kode
INA-CBG
97
E-1-20-i
98
E-1-20-ii
99
E-1-20-iii
100
E-4-10-i
101
E-4-10-ii
102
E-4-10-iii
103
E-4-11-i
104
E-4-11-ii
105
E-4-11-iii
106
E-4-12-i
107
E-4-12-ii
108
E-4-12-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.336.038
4.466.119
4.552.840
4.639.560
5.807.422
5.981.644
6.097.793
6.213.941
12.867.606
13.253.634
13.510.986
13.768.338
1.916.232
1.973.719
2.012.044
2.050.369
2.725.286
2.807.044
2.861.550
2.916.056
5.209.330
5.365.610
5.469.797
5.573.983
1.634.947
1.683.995
1.716.694
1.749.393
3.093.039
3.185.830
3.247.691
3.309.552
5.100.564
5.253.581
5.355.592
5.457.603
1.953.533
2.012.139
2.051.210
2.090.281
3.393.655
3.495.465
3.563.338
3.631.211
5.541.579
5.707.827
5.818.658
5.929.490
2.060.595
2.122.413
2.163.625
2.204.837
3.538.056
3.644.198
3.714.959
3.785.720
6.121.731
6.305.383
6.427.818
6.550.252

RINGAN
SEDANG
BERAT

RINGAN
SEDANG
BERAT
109
E-4-13-i
110
E-4-13-ii
111
E-4-13-iii
112
F-4-10-i
SCHIZOFRENIA RINGAN
2.519.467
2.595.051
2.645.441
2.695.830
113
F-4-10-ii
SCHIZOFRENIA SEDANG
2.797.950
2.881.888
2.937.847
2.993.806
114
F-4-10-iii
SCHIZOFRENIA BERAT
4.142.426
4.266.699
4.349.547
4.432.396
115
F-4-11-i
2.322.339
2.392.009
2.438.456
2.484.902
116
F-4-11-ii
2.705.745
2.786.917
2.841.032
2.895.147
117
F-4-11-iii
DEPRESI MAYOR BERAT
3.469.754
3.573.847
3.643.242
3.712.637
1.149.739
1.184.232
1.207.226
1.230.221
1.641.665
1.690.915
1.723.748
1.756.581
3.561.316
3.668.156
3.739.382
3.810.609

IMPULSE RINGAN
IMPULSE SEDANG
IMPULSE BERAT
118
F-4-12-i
119
F-4-12-ii
120
F-4-12-iii
121
F-4-13-i
1.876.802
1.933.107
1.970.643
2.008.179
122
F-4-13-ii
2.485.369
2.559.930
2.609.637
2.659.345
123
F-4-13-iii
3.204.566
3.300.703
3.364.794
3.428.885
124
F-4-14-i
DEPRESI RINGAN
1.313.762
1.353.175
1.379.450
1.405.725
125
F-4-14-ii
DEPRESI SEDANG
1.685.166
1.735.721
1.769.424
1.803.127
126
F-4-14-iii
DEPRESI BERAT
2.267.466
2.335.490
2.380.839
2.426.188
127
F-4-15-i
1.561.988
1.608.848
1.640.087
1.671.327
128
F-4-15-ii
2.299.479
2.368.463
2.414.453
2.460.442
129
F-4-15-iii
3.028.555
3.119.411
3.179.982
3.240.554
- 699 No
Kode
INA-CBG
130
F-4-16-i
131
F-4-16-ii
132
F-4-16-iii
133
F-4-17-i
134
F-4-17-ii
135
F-4-17-iii
136
F-4-18-i
137
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.364.216
3.465.143
3.532.427
3.599.712
3.910.817
4.028.142
4.106.358
4.184.575
5.220.288
5.376.897
5.481.303
5.585.708
776.758
800.060
815.596
831.131
2.276.603
2.344.901
2.390.433
2.435.965
2.428.968
2.501.837
2.550.416
2.598.996
2.915.989
3.003.469
3.061.789
3.120.109
F-4-18-ii
3.208.412
3.304.664
3.368.833
3.433.001
138
F-4-18-iii
4.946.047
5.094.428
5.193.349
5.292.270
139
F-4-19-i
2.236.289
2.303.377
2.348.103
2.392.829
140
F-4-19-ii
2.863.625
2.949.534
3.006.807
3.064.079
141
F-4-19-iii
3.565.252
3.672.209
3.743.514
3.814.819
142
G-1-01-i
7.109.639
7.322.928
7.465.121
7.607.314
143
G-1-01-ii
12.033.921
12.394.938
12.635.617
12.876.295
144
G-1-01-iii
23.296.327
23.995.216
24.461.143
24.927.069
145
G-1-10-i
3.548.069
3.654.511
3.725.472
3.796.433
146
G-1-10-ii
5.008.991
5.159.260
5.259.440
5.359.620
147
G-1-10-iii
5.936.724
6.114.826
6.233.560
6.352.294
148
G-1-11-i
4.092.803
4.215.587
4.297.443
4.379.299
149
G-1-11-ii
8.404.879
8.657.026
8.825.123
8.993.221
150
G-1-11-iii
17.599.053
18.127.024
18.479.005
18.830.986
151
G-1-12-i
3.182.995
3.278.485
3.342.145
3.405.804
152
G-1-12-ii
7.287.150
7.505.764
7.651.507
7.797.250
153
G-1-12-iii
12.852.934
13.238.522
13.495.581
13.752.639
154
G-1-13-i
839.455
864.639
881.428
898.217
155
G-1-13-ii
2.254.684
2.322.324
2.367.418
2.412.512
156
G-1-13-iii
5.087.516
5.240.142
5.341.892
5.443.642
4.010.844
4.131.169
4.211.386
4.291.603
5.418.782
5.581.345
5.689.721
5.798.097
13.267.250
13.665.268
13.930.613
14.195.958

RINGAN
SEDANG
BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

RINGAN
SEDANG
BERAT
157
G-1-20-i
158
G-1-20-ii
159
G-1-20-iii
160
G-1-30-i
5.115.471
5.268.935
5.371.244
5.473.554
161
G-1-30-ii
13.351.869
13.752.425
14.019.463
14.286.500
162
G-1-30-iii
17.187.982
17.703.621
18.047.381
18.391.140
- 700 No
Kode
INA-CBG
163
G-4-10-i
164
G-4-10-ii
165
G-4-10-iii
166
G-4-11-i
167
G-4-11-ii
168
G-4-11-iii
169
G-4-12-i
170
G-4-12-ii
171
G-4-12-iii
172
G-4-13-i
173
G-4-13-ii
174
G-4-13-iii
175
G-4-14-i
176
G-4-14-ii
177
G-4-14-iii
178
G-4-15-i
179
G-4-15-ii
180
G-4-15-iii
181
G-4-16-i
182
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.299.479
2.368.463
2.414.453
2.460.442
2.682.725
2.763.207
2.816.862
2.870.516
4.098.460
4.221.414
4.303.383
4.385.353
3.793.975
3.907.795
3.983.674
4.059.554
4.401.011
4.533.042
4.621.062
4.709.082
6.449.758
6.643.251
6.772.246
6.901.241
2.837.560
2.922.686
2.979.438
3.036.189
3.575.325
3.682.585
3.754.091
3.825.598
5.192.734
5.348.516
5.452.371
5.556.226
1.578.799
1.626.163
1.657.739
1.689.315
2.682.725
2.763.207
2.816.862
2.870.516
3.171.362
3.266.503
3.329.930
3.393.358
2.887.388
2.974.010
3.031.758
3.089.506
4.750.728
4.893.250
4.988.265
5.083.279
5.948.020
6.126.461
6.245.421
6.364.381
2.955.326
3.043.986
3.103.092
3.162.199
3.571.068
3.678.200
3.749.622
3.821.043
4.412.866
4.545.252
4.633.510
4.721.767
1.916.232
1.973.719
2.012.044
2.050.369
G-4-16-ii
2.865.743
2.951.715
3.009.030
3.066.345
183
G-4-16-iii
5.200.811
5.356.836
5.460.852
5.564.868
184
G-4-17-i
2.738.471
2.820.625
2.875.395
2.930.164
185
G-4-17-ii
3.398.563
3.500.520
3.568.492
3.636.463
186
G-4-17-iii
5.696.020
5.866.901
5.980.821
6.094.742
187
G-4-18-i
2.299.479
2.368.463
2.414.453
2.460.442
188
G-4-18-ii
3.297.055
3.395.966
3.461.907
3.527.848
189
G-4-18-iii
3.492.894
3.597.681
3.667.538
3.737.396
190
G-4-19-i
1.916.232
1.973.719
2.012.044
2.050.369
191
G-4-19-ii
3.883.503
4.000.008
4.077.678
4.155.348

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
DEGENERATIF RINGAN
DEGENERATIF SEDANG
DEGENERATIF BERAT
RINGAN
SEDANG
BERAT
TRAUMATIK RINGAN
TRAUMATIK SEDANG
TRAUMATIK BERAT
DENGAN INFARK BERAT
TANPA INFARK RINGAN
TANPA INFARK SEDANG
TANPA INFARK BERAT

PERIFER RINGAN
PERIFER SEDANG
PERIFER BERAT
PERSARAFAN RINGAN
PERSARAFAN SEDANG
PERSARAFAN BERAT
RINGAN
SEDANG
- 701 No
Kode
INA-CBG
192
G-4-19-iii
193
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

5.792.953
5.966.742
6.082.601
6.198.460
G-4-20-i
1.341.363
1.381.604
1.408.431
1.435.258
194
G-4-20-ii
1.904.736
1.961.879
1.999.973
2.038.068
195
G-4-20-iii
3.248.022
3.345.463
3.410.423
3.475.383
196
G-4-21-i
1.554.333
1.600.963
1.632.049
1.663.136
197
G-4-21-ii
3.219.178
3.315.754
3.380.137
3.444.521
198
G-4-21-iii
3.792.572
3.906.349
3.982.200
4.058.052
199
G-4-22-i
1.532.986
1.578.975
1.609.635
1.640.295
200
G-4-22-ii
1.916.232
1.973.719
2.012.044
2.050.369
201
G-4-22-iii
2.198.419
2.264.372
2.308.340
2.352.309
202
G-4-23-i
1.532.986
1.578.975
1.609.635
1.640.295
203
G-4-23-ii
1.916.232
1.973.719
2.012.044
2.050.369
204
G-4-23-iii
2.739.118
2.821.292
2.876.074
2.930.857
205
G-4-24-i
1.532.986
1.578.975
1.609.635
1.640.295
206
G-4-24-ii
1.916.232
1.973.719
2.012.044
2.050.369
207
G-4-24-iii
TRAUMA KEPALA BERAT
4.026.755
4.147.558
4.228.093
4.308.628
208
G-4-25-i
GEGAR OTAK RINGAN
1.456.636
1.500.335
1.529.468
1.558.600
209
G-4-25-ii
GEGAR OTAK SEDANG
1.833.937
1.888.955
1.925.634
1.962.312
210
G-4-25-iii
GEGAR OTAK BERAT
2.392.780
2.464.564
2.512.419
2.560.275
211
G-4-26-i
2.299.479
2.368.463
2.414.453
2.460.442
212
G-4-26-ii
2.682.725
2.763.207
2.816.862
2.870.516
213
G-4-26-iii
5.120.947
5.274.576
5.376.995
5.479.414
214
H-1-20-i
2.203.501
2.269.606
2.313.676
2.357.746
215
H-1-20-ii
4.018.334
4.138.884
4.219.250
4.299.617
216
H-1-20-iii
5.464.683
5.628.623
5.737.917
5.847.211
2.157.437
2.222.161
2.265.309
2.308.458
2.459.479
2.533.263
2.582.453
2.631.642

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)

RINGAN
SEDANG
217
H-1-30-i
218
H-1-30-ii
219
H-1-30-iii
4.103.551
4.226.658
4.308.729
4.390.800
220
H-4-10-i
2.299.479
2.368.463
2.414.453
2.460.442
221
H-4-10-ii
3.832.465
3.947.439
4.024.088
4.100.737
222
H-4-10-iii
6.248.049
6.435.491
6.560.452
6.685.413
223
H-4-11-i
1.565.692
1.612.663
1.643.977
1.675.291
224
H-4-11-ii
1.749.428
1.801.911
1.836.900
1.871.888
225
H-4-11-iii
2.501.519
2.576.564
2.626.595
2.676.625
- 702 No
Kode
INA-CBG
226
H-4-12-i
227
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.172.336
2.237.506
2.280.952
2.324.399
H-4-12-ii
2.942.571
3.030.848
3.089.699
3.148.551
228
H-4-12-iii
4.909.479
5.056.763
5.154.953
5.253.142
229
I-1-01-i
33.072.334
34.064.505
34.725.951
35.387.398
230
I-1-01-ii
33.800.098
34.814.101
35.490.103
36.166.105
231
I-1-01-iii
53.352.807
54.953.391
56.020.447
57.087.503
232
I-1-02-i
18.348.341
18.898.791
19.265.758
19.632.725
233
I-1-02-ii
23.669.359
24.379.440
24.852.827
25.326.215
234
I-1-02-iii
29.173.862
30.049.078
30.632.555
31.216.032
235
I-1-03-i
11.299.561
11.638.548
11.864.539
12.090.530
236
I-1-03-ii
15.487.993
15.952.633
16.262.393
16.572.153
237
I-1-03-iii
22.715.724
23.397.195
23.851.510
24.305.824
238
I-1-04-i
13.785.133
14.198.687
14.474.390
14.750.093
239
I-1-04-ii
17.707.248
18.238.466
18.592.611
18.946.756
240
I-1-04-iii
37.748.177
38.880.622
39.635.586
40.390.550
241
I-1-05-i
24.284.569
25.013.106
25.498.797
25.984.488
242
I-1-05-ii
29.141.482
30.015.727
30.598.556
31.181.386
243
I-1-05-iii
40.098.496
41.301.451
42.103.420
42.905.390
244
I-1-06-i
11.447.207
11.790.623
12.019.567
12.248.511
245
I-1-06-ii
17.276.553
17.794.849
18.140.380
18.485.911
246
I-1-06-iii
22.241.100
22.908.333
23.353.155
23.797.977
15.053.944
15.505.562
15.806.641
16.107.720
18.572.098
19.129.261
19.500.703
19.872.145
20.262.038
20.869.899
21.275.140
21.680.381
2.863.627
2.949.536
3.006.809
3.064.081
3.184.067
3.279.589
3.343.270
3.406.952
4.237.023
4.364.134
4.448.874
4.533.614
8.776.530
9.039.825
9.215.356
9.390.887
12.177.845
12.543.180
12.786.737
13.030.294
247
I-1-07-i
248
I-1-07-ii
249
I-1-07-iii
250
I-1-11-i
251
I-1-11-ii
252
I-1-11-iii
253
I-1-12-i
254
I-1-12-ii

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
KATETERISASI RINGAN
KATETERISASI SEDANG
KATETERISASI BERAT
RINGAN
SEDANG
BERAT

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
- 703 No
Kode
INA-CBG
255
I-1-12-iii
256
I-1-13-i
257
I-1-13-ii
258
I-1-13-iii
259
I-1-14-i
260
I-1-14-ii
261
I-1-14-iii
262
I-1-15-i
263
I-1-15-ii
264
I-1-15-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
16.985.218
17.494.775
17.834.479
18.174.184
5.162.664
5.317.544
5.420.798
5.524.051
6.006.444
6.186.637
6.306.766
6.426.895
10.949.345
11.277.826
11.496.813
11.715.799
18.887.998
19.454.638
19.832.398
20.210.158
23.475.083
24.179.335
24.648.837
25.118.339
30.760.453
31.683.267
32.298.476
32.913.685
3.701.142
3.812.176
3.886.199
3.960.222
10.841.595
11.166.843
11.383.675
11.600.507
56.117.717
57.801.248
58.923.602
60.045.957
8.094.856
8.337.702
8.499.599
8.661.496
21.046.626
21.678.025
22.098.957
22.519.890
24.276.767
25.005.070
25.490.605
25.976.140
2.596.085
2.673.968
2.725.890
2.777.811
5.377.434
5.538.757
5.646.306
5.753.855
31.175.092
32.110.345
32.733.847
33.357.349
3.097.599
3.190.527
3.252.478
3.314.430
5.575.677
5.742.948
5.854.461
5.965.975
7.434.237
7.657.264
7.805.949
7.954.633
9.183.656
9.459.166
9.642.839
9.826.512
19.103.861
19.676.976
20.059.054
20.441.131
29.604.045
30.492.167
31.084.248
31.676.329
12.349.948
12.720.446
12.967.445
13.214.444
17.151.424
17.665.967
18.008.996
18.352.024
21.491.521
22.136.267
22.566.097
22.995.927

KOMPLEKS BERAT
KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

DARAH VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
265
I-1-16-i
266
I-1-16-ii
267
I-1-16-iii
268
I-1-17-i
269
I-1-17-ii
270
I-1-17-iii
271
I-1-20-i
272
I-1-20-ii
273
I-1-20-iii
274
I-1-30-i
275
I-1-30-ii
276
I-1-30-iii
277
I-1-40-i
278
I-1-40-ii
279
I-1-40-iii
280
I-4-10-i
3.591.724
3.699.475
3.771.310
3.843.144
281
I-4-10-ii
5.671.396
5.841.538
5.954.966
6.068.394
282
I-4-10-iii
8.181.483
8.426.928
8.590.558
8.754.187
283
I-4-11-i
4.258.845
4.386.610
4.471.787
4.556.964
- 704 No
Kode
INA-CBG
284
I-4-11-ii
285
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.270.337
5.428.447
5.533.854
5.639.261
I-4-11-iii
9.327.246
9.607.063
9.793.608
9.980.153
286
I-4-12-i
3.730.305
3.842.215
3.916.821
3.991.427
287
I-4-12-ii
5.323.135
5.482.829
5.589.292
5.695.755
288
I-4-12-iii
6.457.712
6.651.443
6.780.598
6.909.752
289
I-4-13-i
3.350.840
3.451.365
3.518.382
3.585.399
290
I-4-13-ii
4.868.086
5.014.129
5.111.491
5.208.852
291
I-4-13-iii
9.964.408
10.263.341
10.462.629
10.661.917
292
I-4-14-i
2.083.913
2.146.430
2.188.108
2.229.787
293
I-4-14-ii
2.438.486
2.511.641
2.560.410
2.609.180
294
I-4-14-iii
3.778.842
3.892.208
3.967.784
4.043.361
295
I-4-15-i
3.065.972
3.157.951
3.219.270
3.280.590
296
I-4-15-ii
4.389.090
4.520.763
4.608.545
4.696.327
297
I-4-15-iii
5.002.507
5.152.582
5.252.633
5.352.683
298
I-4-16-i
2.299.479
2.368.463
2.414.453
2.460.442
299
I-4-16-ii
3.726.663
3.838.463
3.912.996
3.987.530
300
I-4-16-iii
4.694.934
4.835.782
4.929.681
5.023.579
301
I-4-17-i
HIPERTENSI RINGAN
2.057.986
2.119.726
2.160.885
2.202.045
302
I-4-17-ii
HIPERTENSI SEDANG
2.914.313
3.001.742
3.060.029
3.118.315
303
I-4-17-iii
HIPERTENSI BERAT
3.545.401
3.651.763
3.722.671
3.793.579
304
I-4-18-i
3.030.822
3.121.747
3.182.363
3.242.980
305
I-4-18-ii
4.643.017
4.782.307
4.875.168
4.968.028
306
I-4-18-iii
6.259.531
6.447.317
6.572.507
6.697.698
307
I-4-19-i
2.372.016
2.443.176
2.490.616
2.538.057
308
I-4-19-ii
3.885.287
4.001.846
4.079.552
4.157.257
309
I-4-19-iii
4.631.227
4.770.164
4.862.788
4.955.413
310
I-4-20-i
2.878.777
2.965.140
3.022.716
3.080.291
311
I-4-20-ii
3.316.566
3.416.063
3.482.394
3.548.726
312
I-4-20-iii
4.401.635
4.533.684
4.621.717
4.709.750
313
I-4-21-i
3.828.307
3.943.157
4.019.723
4.096.289
314
I-4-21-ii
4.775.565
4.918.832
5.014.343
5.109.855
315
I-4-21-iii
6.514.883
6.710.330
6.840.628
6.970.925
316
I-4-22-i
2.491.102
2.565.835
2.615.657
2.665.479

VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT


RINGAN
SEDANG
KONGENITAL BERAT
RINGAN
SEDANG
BERAT
- 705 No
Kode
INA-CBG
317
I-4-22-ii
318
I-4-22-iii
319
I-4-23-i
320
I-4-23-ii
321
I-4-23-iii
322
I-4-24-i
323
I-4-24-ii
324
I-4-24-iii
325
J-1-01-i
326
J-1-01-ii
327
J-1-01-iii
328
J-1-02-i
329
J-1-02-ii
330
J-1-02-iii
331
J-1-10-i
332
J-1-10-ii
333
J-1-10-iii
334
J-1-20-i
335
J-1-20-ii
336
J-1-20-iii
337
J-1-30-i
338
J-1-30-ii
339
J-1-30-iii
340
J-4-10-i
341
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.870.495
2.956.610
3.014.020
3.071.430
4.187.975
4.313.614
4.397.373
4.481.133
1.887.150
1.943.765
1.981.508
2.019.251
2.316.986
2.386.495
2.432.835
2.479.175
4.527.179
4.662.994
4.753.538
4.844.081
2.250.825
2.318.350
2.363.367
2.408.383
5.619.688
5.788.279
5.900.673
6.013.067
7.105.081
7.318.233
7.460.335
7.602.436
18.485.086
19.039.639
19.409.341
19.779.042
20.134.391
20.738.423
21.141.111
21.543.799
33.098.388
34.091.340
34.753.307
35.415.275
9.269.848
9.547.943
9.733.340
9.918.737
9.930.477
10.228.391
10.427.001
10.625.610
14.674.415
15.114.648
15.408.136
15.701.624
3.617.229
3.725.746
3.798.090
3.870.435
8.736.922
8.999.029
9.173.768
9.348.506
15.469.794
15.933.887
16.243.283
16.552.679
3.126.443
3.220.236
3.282.765
3.345.294
4.547.164
4.683.579
4.774.523
4.865.466
6.837.531
7.042.657
7.179.407
7.316.158
2.108.333
2.171.583
2.213.750
2.255.916
10.325.329
10.635.089
10.841.595
11.048.102
31.140.739
32.074.961
32.697.776
33.320.590
2.433.298
2.506.297
2.554.963
2.603.629
J-4-10-ii
3.479.324
3.583.703
3.653.290
3.722.876
342
J-4-10-iii
5.263.697
5.421.608
5.526.882
5.632.156
343
J-4-11-i
1.535.101
1.581.154
1.611.857
1.642.559
344
J-4-11-ii
2.136.826
2.200.931
2.243.667
2.286.404
345
J-4-11-iii
3.062.126
3.153.990
3.215.233
3.276.475
346
J-4-12-i
EMBOLI PARU RINGAN
2.347.569
2.417.996
2.464.947
2.511.899
347
J-4-12-ii
EMBOLI PARU SEDANG
3.040.021
3.131.222
3.192.022
3.252.823

RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
- 706 No
Kode
INA-CBG
348
J-4-12-iii
349
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
EMBOLI PARU BERAT
4.059.641
4.181.430
4.262.623
4.343.816
J-4-13-i
3.616.147
3.724.632
3.796.955
3.869.278
350
J-4-13-ii
5.315.737
5.475.209
5.581.523
5.687.838
351
J-4-13-iii
8.642.592
8.901.870
9.074.722
9.247.574
352
J-4-14-i
TUMOR PARU RINGAN
2.464.290
2.538.219
2.587.505
2.636.790
353
J-4-14-ii
TUMOR PARU SEDANG
4.128.023
4.251.864
4.334.424
4.416.985
354
J-4-14-iii
TUMOR PARU BERAT
4.908.010
5.055.250
5.153.410
5.251.571
355
J-4-15-i
2.299.479
2.368.463
2.414.453
2.460.442
356
J-4-15-ii
4.161.244
4.286.081
4.369.306
4.452.531
357
J-4-15-iii
5.199.391
5.355.373
5.459.361
5.563.348
358
J-4-16-i
1.916.232
1.973.719
2.012.044
2.050.369
359
J-4-16-ii
2.682.725
2.763.207
2.816.862
2.870.516
360
J-4-16-iii
4.839.354
4.984.535
5.081.322
5.178.109
361
J-4-17-i
2.393.078
2.464.870
2.512.732
2.560.593
362
J-4-17-ii
3.233.459
3.330.463
3.395.132
3.459.802
363
J-4-17-iii
4.227.460
4.354.283
4.438.833
4.523.382
364
J-4-18-i
2.153.093
2.217.686
2.260.748
2.303.809
365
J-4-18-ii
2.997.968
3.087.907
3.147.866
3.207.825
366
J-4-18-iii
3.109.555
3.202.842
3.265.033
3.327.224
367
J-4-19-i
2.682.725
2.763.207
2.816.862
2.870.516
368
J-4-19-ii
3.065.972
3.157.951
3.219.270
3.280.590
369
J-4-19-iii
4.803.204
4.947.300
5.043.365
5.139.429
370
J-4-20-i
2.682.725
2.763.207
2.816.862
2.870.516
371
J-4-20-ii
3.272.429
3.370.602
3.436.051
3.501.499
372
J-4-20-iii
7.394.510
7.616.345
7.764.236
7.912.126
373
J-4-21-i
1.532.986
1.578.975
1.609.635
1.640.295
374
J-4-21-ii
3.782.156
3.895.621
3.971.264
4.046.907
375
J-4-21-iii
5.394.592
5.556.429
5.664.321
5.772.213
376
K-1-10-i
4.130.132
4.254.036
4.336.638
4.419.241
377
K-1-10-ii
5.763.870
5.936.786
6.052.063
6.167.341
378
K-1-10-iii
6.750.484
6.952.999
7.088.008
7.223.018
379
K-1-11-i
3.551.278
3.657.816
3.728.842
3.799.867
380
K-1-11-ii
4.662.399
4.802.271
4.895.519
4.988.767

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT

USUS BESAR (RINGAN)
USUS BESAR (SEDANG)
USUS BESAR (BERAT)
- 707 No
Kode
INA-CBG
381
K-1-11-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
11.832.252
12.187.219
12.423.864
12.660.509
1.910.316
1.967.625
2.005.831
2.044.038
2.489.732
2.564.424
2.614.219
2.664.014
4.952.601
5.101.179
5.200.231
5.299.283
382
K-1-12-i
383
K-1-12-ii
384
K-1-12-iii
385
K-1-13-i
2.169.857
2.234.953
2.278.350
2.321.747
386
K-1-13-ii
3.790.117
3.903.820
3.979.622
4.055.425
387
K-1-13-iii
4.053.393
4.174.995
4.256.063
4.337.130
3.506.617
3.611.816
3.681.948
3.752.080
4.118.919
4.242.487
4.324.865
4.407.243
10.141.973
10.446.232
10.649.071
10.851.911

RINGAN
SEDANG
BERAT
388
K-1-14-i
389
K-1-14-ii
390
K-1-14-iii
391
K-1-20-i
6.803.866
7.007.982
7.144.059
7.280.136
392
K-1-20-ii
9.496.402
9.781.294
9.971.222
10.161.150
393
K-1-20-iii
20.284.764
20.893.307
21.299.002
21.704.697
394
K-1-30-i
4.478.643
4.613.002
4.702.575
4.792.148
395
K-1-30-ii
8.260.263
8.508.071
8.673.276
8.838.482
396
K-1-30-iii
12.864.300
13.250.229
13.507.515
13.764.801
397
K-1-40-i
4.499.338
4.634.318
4.724.304
4.814.291
398
K-1-40-ii
4.951.074
5.099.606
5.198.628
5.297.649
399
K-1-40-iii
8.210.880
8.457.206
8.621.424
8.785.641
400
K-1-50-i
3.431.909
3.534.866
3.603.504
3.672.143
401
K-1-50-ii
4.444.484
4.577.819
4.666.708
4.755.598
402
K-1-50-iii
PROSEDUR ANAL BERAT
6.309.985
6.499.285
6.625.485
6.751.684
403
K-4-10-i
2.599.424
2.677.407
2.729.395
2.781.384
404
K-4-10-ii
3.110.364
3.203.675
3.265.882
3.328.089
405
K-4-10-iii
12.879.976
13.266.375
13.523.975
13.781.574
406
K-4-11-i
1.532.986
1.578.975
1.609.635
1.640.295
407
K-4-11-ii
2.299.479
2.368.463
2.414.453
2.460.442
408
K-4-11-iii
4.178.982
4.304.351
4.387.931
4.471.510
409
K-4-12-i
1.532.986
1.578.975
1.609.635
1.640.295
410
K-4-12-ii
2.290.257
2.358.965
2.404.770
2.450.575
411
K-4-12-iii
5.496.454
5.661.348
5.771.277
5.881.206
412
K-4-13-i

(RINGAN)
2.299.479
2.368.463
2.414.453
2.460.442

(RINGAN)
(SEDANG)
(BERAT)
- 708 No
Kode
INA-CBG
413
K-4-13-ii
414
K-4-13-iii
415
K-4-14-i
416
K-4-14-ii
417
K-4-14-iii
418
K-4-15-i
419
K-4-15-ii
420
K-4-15-iii
421
K-4-16-i
422
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.978.391
3.067.743
3.127.311
3.186.879
4.871.345
5.017.485
5.114.912
5.212.339
1.916.232
1.973.719
2.012.044
2.050.369
2.593.421
2.671.223
2.723.092
2.774.960
3.922.796
4.040.480
4.118.936
4.197.392
1.916.232
1.973.719
2.012.044
2.050.369
3.603.040
3.711.131
3.783.192
3.855.252
5.126.477
5.280.271
5.382.801
5.485.330
1.916.232
1.973.719
2.012.044
2.050.369
K-4-16-ii
2.299.479
2.368.463
2.414.453
2.460.442
423
K-4-16-iii
2.806.813
2.891.017
2.947.153
3.003.290
424
K-4-17-i
1.532.986
1.578.975
1.609.635
1.640.295
425
K-4-17-ii
2.236.655
2.303.755
2.348.488
2.393.221
426
K-4-17-iii
2.976.760
3.066.062
3.125.598
3.185.133
427
K-4-18-i
1.532.986
1.578.975
1.609.635
1.640.295
428
K-4-18-ii
2.379.830
2.451.225
2.498.822
2.546.418
429
K-4-18-iii
2.815.327
2.899.787
2.956.093
3.012.400
430
L-1-20-i
15.687.430
16.158.053
16.471.802
16.785.550
431
L-1-20-ii
16.319.252
16.808.829
17.135.214
17.461.600
432
L-1-20-iii
25.002.978
25.753.067
26.253.127
26.753.186
433
L-1-30-i
486.839
501.444
511.180
520.917
434
L-1-30-ii
705.187
726.343
740.447
754.550
435
L-1-30-iii
743.752
766.065
780.940
795.815
436
L-1-40-i
196.571
202.468
206.400
210.331
437
L-1-40-ii
442.423
455.696
464.544
473.392
438
L-1-40-iii
749.790
772.284
787.279
802.275
439
L-1-50-i
5.162.664
5.317.544
5.420.798
5.524.051
440
L-1-50-ii
9.292.796
9.571.580
9.757.436
9.943.292
441
L-1-50-iii
11.236.305
11.573.394
11.798.120
12.022.847
442
L-4-10-i
157.332
162.052
165.199
168.345
443
L-4-10-ii
183.554
189.061
192.732
196.403

(SEDANG)
RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
- 709 No
Kode
INA-CBG
444
L-4-10-iii
445
L-4-11-i
446
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
371.315
382.454
389.880
397.307
2.174.888
2.240.135
2.283.633
2.327.130
L-4-11-ii
2.979.559
3.068.946
3.128.537
3.188.128
447
L-4-11-iii
8.080.191
8.322.597
8.484.200
8.645.804
448
L-4-12-i
157.332
162.052
165.199
168.345
449
L-4-12-ii
230.843
237.768
242.385
247.002
450
L-4-12-iii
387.096
398.709
406.451
414.193
451
L-4-13-i
1.443.313
1.486.613
1.515.479
1.544.345
452
L-4-13-ii
1.664.226
1.714.152
1.747.437
1.780.721
453
L-4-13-iii
2.496.468
2.571.362
2.621.292
2.671.221
454
L-4-14-i
104.888
108.035
110.133
112.230
455
L-4-14-ii
157.332
162.052
165.199
168.345
456
L-4-14-iii
245.992
253.372
258.291
263.211
457
M-1-01-i
511.371
526.712
536.939
547.167
458
M-1-01-ii
570.772
587.896
599.311
610.726
459
M-1-01-iii
801.780
825.834
841.870
857.905
460
M-1-02-i
326.696
336.497
343.031
349.565
461
M-1-02-ii
536.373
552.464
563.191
573.919
462
M-1-02-iii
971.346
1.000.487
1.019.914
1.039.341
463
M-1-03-i
877.786
904.120
921.676
939.231
464
M-1-03-ii
1.054.347
1.085.977
1.107.064
1.128.151
465
M-1-03-iii
1.095.025
1.127.875
1.149.776
1.171.676
466
M-1-04-i
215.512
221.977
226.287
230.597
467
M-1-04-ii
276.284
284.572
290.098
295.623
468
M-1-04-iii
345.717
356.088
363.003
369.917
469
M-1-05-i
335.726
345.797
352.512
359.226
470
M-1-05-ii
388.009
399.649
407.409
415.169
471
M-1-05-iii
660.885
680.711
693.929
707.147
472
M-1-07-i
410.847
423.172
431.389
439.606
473
M-1-07-ii
550.407
566.919
577.927
588.935
474
M-1-07-iii
1.121.230
1.154.867
1.177.292
1.199.717
475
M-1-10-i
231.614
238.563
243.195
247.827


TULANG WAJAH RINGAN
- 710 No
Kode
INA-CBG
476
M-1-10-ii
477
M-1-10-iii
478
M-1-20-i
479
M-1-20-ii
480
M-1-20-iii
481
M-1-30-i
482
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
860.672
886.492
903.706
920.919
1.073.549
1.105.756
1.127.227
1.148.698
229.126
236.000
240.583
245.165
326.781
336.585
343.120
349.656
635.728
654.800
667.514
680.229
137.052
141.163
143.904
146.645
M-1-30-ii
283.184
291.679
297.343
303.007
483
M-1-30-iii
PROSEDUR KAKI BERAT
422.450
435.124
443.573
452.022
484
M-1-40-i
153.521
158.127
161.198
164.268
485
M-1-40-ii
282.587
291.065
296.716
302.368
486
M-1-40-iii
494.527
509.363
519.254
529.144
487
M-1-50-i
183.399
188.901
192.569
196.237
488
M-1-50-ii
369.188
380.263
387.647
395.031
489
M-1-50-iii
565.174
582.129
593.433
604.736
490
M-1-60-i
138.409
142.561
145.329
148.097
491
M-1-60-ii
277.095
285.408
290.950
296.492
492
M-1-60-iii
482.244
496.711
506.356
516.001
493
M-1-70-i
185.412
190.974
194.683
198.391
494
M-1-70-ii
378.332
389.682
397.249
404.816
495
M-1-70-iii
609.918
628.215
640.414
652.612
496
M-1-80-i
149.392
153.874
156.862
159.849
497
M-1-80-ii
225.850
232.626
237.143
241.660
498
M-1-80-iii
519.965
535.564
545.964
556.363
499
M-4-10-i
104.888
108.035
110.133
112.230
500
M-4-10-ii
157.332
162.052
165.199
168.345
501
M-4-10-iii
FRAKTUR FEMUR BERAT
306.527
315.723
321.854
327.984
502
M-4-11-i
131.110
135.043
137.666
140.288
503
M-4-11-ii
287.259
295.877
301.622
307.367
504
M-4-11-iii
509.878
525.174
535.372
545.569
505
M-4-12-i
104.888
108.035
110.133
112.230
506
M-4-12-ii
190.844
196.569
200.386
204.203

TULANG WAJAH SEDANG
TULANG WAJAH BERAT

RINGAN
SEDANG
BERAT

SELAIN KAKI (BERAT)

PANGGUL RINGAN
PANGGUL SEDANG
PANGGUL BERAT
PELVIS RINGAN
PELVIS SEDANG
- 711 No
Kode
INA-CBG
507
M-4-12-iii
508
M-4-13-i
509
M-4-13-ii
510
M-4-13-iii
511
M-4-14-i
512
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
344.763
355.106
362.001
368.897
174.662
179.901
183.395
186.888
262.220
270.087
275.331
280.576
519.574
535.162
545.553
555.944
198.861
204.827
208.804
212.781
M-4-14-ii
245.663
253.033
257.946
262.859
513
M-4-14-iii
OSTEOMIELITIS BERAT
367.976
379.015
386.375
393.735
514
M-4-15-i
118.055
121.597
123.958
126.319
515
M-4-15-ii
157.417
162.139
165.288
168.436
516
M-4-15-iii
445.775
459.148
468.063
476.979
517
M-4-16-i
131.110
135.043
137.666
140.288
518
M-4-16-ii
209.776
216.070
220.265
224.461
519
M-4-16-iii
351.847
362.403
369.440
376.477
520
M-4-17-i
131.110
135.043
137.666
140.288
521
M-4-17-ii
183.554
189.061
192.732
196.403
522
M-4-17-iii
256.343
264.034
269.160
274.287
523
M-4-18-i
138.624
142.783
145.556
148.328
524
M-4-18-ii
209.776
216.070
220.265
224.461
525
M-4-18-iii
235.099
242.152
246.854
251.556
526
M-4-19-i
103.069
106.161
108.223
110.284
527
M-4-19-ii
173.602
178.810
182.282
185.754
528
M-4-19-iii
339.057
349.228
356.009
362.791
529
M-4-20-i
104.888
108.035
110.133
112.230
530
M-4-20-ii
157.332
162.052
165.199
168.345
531
M-4-20-iii
174.361
179.592
183.079
186.566
532
M-4-21-i
104.888
108.035
110.133
112.230
533
M-4-21-ii
131.110
135.043
137.666
140.288
534
M-4-21-iii
301.021
310.052
316.073
322.093
535
N-1-01-i
4.147.845
4.272.281
4.355.237
4.438.194
536
N-1-01-ii
5.609.867
5.778.163
5.890.360
6.002.558
537
N-1-01-iii
11.894.587
12.251.424
12.489.316
12.727.208

PELVIS BERAT

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
RINGAN
SEDANG
BERAT
ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
- 712 No
Kode
INA-CBG
538
N-1-11-i
539
N-1-11-ii
540
N-1-11-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.722.273
5.893.941
6.008.386
6.122.832
7.739.245
7.971.422
8.126.207
8.280.992
16.409.501
16.901.786
17.229.976
17.558.166
3.097.599
3.190.527
3.252.479
3.314.431
7.206.344
7.422.534
7.566.661
7.710.788
13.134.011
13.528.031
13.790.712
14.053.392
541
N-1-12-i
542
N-1-12-ii
543
N-1-12-iii
544
N-1-20-i
4.193.904
4.319.721
4.403.599
4.487.477
545
N-1-20-ii
8.315.021
8.564.471
8.730.772
8.897.072
546
N-1-20-iii
9.511.630
9.796.979
9.987.211
10.177.444
547
N-1-30-i
4.989.389
5.139.071
5.238.858
5.338.646
548
N-1-30-ii
7.581.999
7.809.459
7.961.099
8.112.739
549
N-1-30-iii
8.728.131
8.989.975
9.164.538
9.339.100
550
N-1-40-i
4.495.928
4.630.806
4.720.724
4.810.643
551
N-1-40-ii
6.094.391
6.277.222
6.399.110
6.520.998
552
N-1-40-iii
7.087.952
7.300.591
7.442.350
7.584.109
553
N-4-10-i
1.916.232
1.973.719
2.012.044
2.050.369
554
N-4-10-ii
2.565.889
2.642.865
2.694.183
2.745.501
555
N-4-10-iii
5.616.269
5.784.757
5.897.082
6.009.407
556
N-4-11-i
1.467.457
1.511.480
1.540.830
1.570.179
557
N-4-11-ii
2.479.967
2.554.366
2.603.965
2.653.564
558
N-4-11-iii
2.874.349
2.960.579
3.018.066
3.075.553
559
N-4-12-i
1.532.986
1.578.975
1.609.635
1.640.295
560
N-4-12-ii
2.299.479
2.368.463
2.414.453
2.460.442
561
N-4-12-iii
3.817.891
3.932.427
4.008.785
4.085.143
562
N-4-13-i
BATU URIN RINGAN
2.022.480
2.083.154
2.123.604
2.164.053
563
N-4-13-ii
BATU URIN SEDANG
2.438.350
2.511.500
2.560.267
2.609.034
564
N-4-13-iii
BATU URIN BERAT
6.004.987
6.185.137
6.305.236
6.425.336
565
N-4-14-i
1.327.850
1.367.685
1.394.242
1.420.799
566
N-4-14-ii
2.044.722
2.106.064
2.146.958
2.187.852
567
N-4-14-iii
3.315.887
3.415.364
3.481.681
3.547.999

URIN BAWAH RINGAN
URIN BAWAH SEDANG
URIN BAWAH BERAT
RINGAN
SEDANG
BERAT
GINJAL RINGAN
GINJAL SEDANG
GINJAL BERAT

(RINGAN)
(SEDANG)
(BERAT)
- 713 No
Kode
INA-CBG
568
N-4-15-i
569
N-4-15-ii
570
N-4-15-iii
571
N-4-16-i
572
N-4-16-ii
573
N-4-16-iii
574
O-6-10-i
575
O-6-10-ii
576
O-6-10-iii
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
584
585
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.969.969
2.029.068
2.068.467
2.107.867
2.703.410
2.784.513
2.838.581
2.892.649
3.085.079
3.177.631
3.239.333
3.301.035
2.556.747
2.633.450
2.684.585
2.735.720
3.065.972
3.157.951
3.219.270
3.280.590
6.447.283
6.640.701
6.769.647
6.898.592
3.775.164
3.888.419
3.963.922
4.039.425
4.191.007
4.316.737
4.400.558
4.484.378
4.698.169
4.839.114
4.933.078
5.027.041
1.973.036
2.032.227
2.071.687
2.111.148
2.531.225
2.607.161
2.657.786
2.708.410
4.289.640
4.418.329
4.504.122
4.589.915
1.718.129
1.769.672
1.804.035
1.838.398
2.063.468
2.125.372
2.166.642
2.207.911
2.592.452
2.670.226
2.722.075
2.773.924
1.721.875
1.773.531
1.807.968
1.842.406
O-6-13-ii
2.537.705
2.613.836
2.664.590
2.715.345
O-6-13-iii
2.999.176
3.089.151
3.149.135
3.209.118
38.517.557
39.673.083
40.443.434
41.213.786
47.659.451
49.089.235
50.042.424
50.995.613
55.938.835
57.617.001
58.735.777
59.854.554
46.667.026
48.067.037
49.000.377
49.933.718
53.531.882
55.137.839
56.208.476
57.279.114
61.164.003
62.998.923
64.222.203
65.445.483
2.581.332
2.658.772
2.710.399
2.762.025
3.613.865
3.722.281
3.794.558
3.866.836
5.692.657
5.863.437
5.977.290
6.091.143
23.053.110
23.744.703
24.205.765
24.666.828
29.917.966
30.815.505
31.413.865
32.012.224
586
P-8-01-i
587
P-8-01-ii
588
P-8-01-iii
589
P-8-02-i
590
P-8-02-ii
591
P-8-02-iii
592
P-8-03-i
593
P-8-03-ii
594
P-8-03-iii
595
P-8-04-i
596
P-8-04-ii

SALURAN URIN RINGAN
SALURAN URIN SEDANG
SALURAN URIN BERAT
RINGAN
SEDANG
BERAT
&KURET RINGAN
KURET SEDANG
KURET BERAT

- 714 No
Kode
INA-CBG
597
P-8-04-iii
598
P-8-05-i
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii
603
P-8-06-iii
604
P-8-07-i
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
614
P-8-11-ii
615
P-8-11-iii
616
P-8-12-i
617
P-8-12-ii
618
P-8-12-iii
619
P-8-13-i
620
P-8-13-ii
621
P-8-13-iii
622
P-8-14-i
623
P-8-14-ii
624
P-8-14-iii
Deskripsi (INA-CBG)
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
RINGAN
SEDANG
BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
42.894.833
44.181.678
45.039.575
45.897.471
12.535.534
12.911.600
13.162.310
13.413.021
17.767.429
18.300.452
18.655.801
19.011.149
26.177.922
26.963.259
27.486.818
28.010.376
2.065.066
2.127.018
2.168.319
2.209.620
5.196.247
5.352.134
5.456.059
5.559.984
9.665.611
9.955.580
10.148.892
10.342.204
3.613.865
3.722.281
3.794.558
3.866.836
10.132.408
10.436.380
10.639.028
10.841.676
13.422.928
13.825.615
14.094.074
14.362.533
2.618.902
2.697.469
2.749.847
2.802.225
3.717.900
3.829.437
3.903.795
3.978.153
5.248.533
5.405.989
5.510.960
5.615.931
1.624.764
1.673.507
1.706.002
1.738.497
2.353.707
2.424.318
2.471.392
2.518.467
4.621.021
4.759.651
4.852.072
4.944.492
4.576.026
4.713.307
4.804.827
4.896.348
9.742.233
10.034.500
10.229.345
10.424.190
9.946.335
10.244.725
10.443.652
10.642.578
2.158.849
2.223.614
2.266.791
2.309.968
3.356.635
3.457.334
3.524.467
3.591.600
3.960.120
4.078.923
4.158.126
4.237.328
1.115.809
1.149.284
1.171.600
1.193.916
2.064.797
2.126.741
2.168.037
2.209.332
3.088.124
3.180.768
3.242.530
3.304.293
2.038.700
2.099.861
2.140.635
2.181.409
4.162.448
4.287.322
4.370.571
4.453.820
4.566.190
4.703.176
4.794.500
4.885.824
- 715 No
Kode
INA-CBG
625
P-8-15-i
626
P-8-15-ii
627
P-8-15-iii
628
P-8-16-i
629
P-8-16-ii
630
P-8-16-iii
631
P-8-17-i
632
P-8-17-ii
633
P-8-17-iii
634
S-4-10-i
635
S-4-10-ii
636
S-4-10-iii
637
S-4-11-i
638
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.533.166
1.579.161
1.609.824
1.640.488
3.064.396
3.156.327
3.217.615
3.278.903
3.599.607
3.707.595
3.779.587
3.851.580
1.387.878
1.429.514
1.457.271
1.485.029
1.968.764
2.027.826
2.067.202
2.106.577
2.555.552
2.632.218
2.683.329
2.734.441
915.996
943.476
961.796
980.116
3.042.629
3.133.908
3.194.761
3.255.613
6.141.353
6.325.594
6.448.421
6.571.248
1.532.986
1.578.975
1.609.635
1.640.295
1.916.232
1.973.719
2.012.044
2.050.369
2.490.773
2.565.496
2.615.312
2.665.127
958.116
986.860
1.006.022
1.025.184
S-4-11-ii
1.458.271
1.502.019
1.531.184
1.560.350
639
S-4-11-iii
2.359.227
2.430.004
2.477.189
2.524.373
640
S-4-12-i
1.149.739
1.184.232
1.207.226
1.230.221
641
S-4-12-ii
1.532.986
1.578.975
1.609.635
1.640.295
642
S-4-12-iii
2.994.043
3.083.864
3.143.745
3.203.626
643
S-4-13-i
1.532.986
1.578.975
1.609.635
1.640.295
644
S-4-13-ii
2.709.975
2.791.275
2.845.474
2.899.674
645
S-4-13-iii
5.517.854
5.683.390
5.793.747
5.904.104
646
S-4-14-i
934.020
962.041
980.721
999.402
647
S-4-14-ii
1.984.172
2.043.697
2.083.381
2.123.064
648
S-4-14-iii
3.762.697
3.875.578
3.950.832
4.026.086
649
S-4-15-i
706.408
727.600
741.728
755.857
650
S-4-15-ii
1.333.233
1.373.230
1.399.894
1.426.559
651
S-4-15-iii
1.726.846
1.778.651
1.813.188
1.847.725
652
S-4-16-i
LUKA BAKAR RINGAN
2.682.725
2.763.207
2.816.862
2.870.516
653
S-4-16-ii
LUKA BAKAR SEDANG
3.788.882
3.902.549
3.978.326
4.054.104
654
S-4-16-iii
LUKA BAKAR BERAT
6.765.637
6.968.606
7.103.919
7.239.232
1.430.482
1.473.396
1.502.006
1.530.615
1.916.232
1.973.719
2.012.044
2.050.369
655
S-4-17-i
656
S-4-17-ii

ASPIRASI RINGAN
ASPIRASI SEDANG
ASPIRASI BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT

PASIEN RINGAN
PASIEN SEDANG
PASIEN BERAT

- 716 No
Kode
INA-CBG
657
S-4-17-iii
658
T-1-10-i
659
T-1-10-ii
660
T-1-10-iii
661
T-4-10-i
662
T-4-10-ii
663
T-4-10-iii
664
T-4-11-i
665
T-4-11-ii
666
T-4-11-iii
667
T-4-12-i
668
T-4-12-ii
669
T-4-12-iii
670
U-1-10-i
671
672
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.124.795
3.218.539
3.281.035
3.343.531
1.476.652
1.520.952
1.550.485
1.580.018
1.983.043
2.042.535
2.082.196
2.121.856
3.607.802
3.716.036
3.788.193
3.860.349
645.930
665.308
678.226
691.145
1.230.999
1.267.929
1.292.549
1.317.169
1.789.538
1.843.224
1.879.015
1.914.806
638.787
657.951
670.727
683.503
1.005.270
1.035.428
1.055.533
1.075.639
1.619.193
1.667.769
1.700.153
1.732.537
1.341.363
1.381.604
1.408.431
1.435.258
2.027.396
2.088.218
2.128.766
2.169.314
3.153.899
3.248.516
3.311.594
3.374.672
1.427.758
1.470.590
1.499.146
1.527.701
U-1-10-ii
2.913.427
3.000.830
3.059.099
3.117.367
U-1-10-iii
12.580.768
12.958.191
13.209.806
13.461.421
6.195.197
6.381.053
6.504.957
6.628.861
8.260.263
8.508.071
8.673.276
8.838.482
13.877.977
14.294.317
14.571.876
14.849.436

DOKTER RINGAN
DOKTER SEDANG
DOKTER BERAT

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
673
U-1-11-i
674
U-1-11-ii
675
U-1-11-iii
676
U-1-12-i
3.785.952
3.899.531
3.975.250
4.050.969
677
U-1-12-ii
9.292.796
9.571.580
9.757.436
9.943.292
678
U-1-12-iii
12.066.872
12.428.878
12.670.215
12.911.553
679
U-1-13-i
4.130.132
4.254.036
4.336.638
4.419.241
680
U-1-13-ii
4.659.909
4.799.706
4.892.904
4.986.103
681
U-1-13-iii
8.985.619
9.255.187
9.434.900
9.614.612
2.278.877
2.347.243
2.392.821
2.438.398
2.796.640
2.880.539
2.936.472
2.992.405
3.314.097
3.413.520
3.479.802
3.546.084

682
U-1-14-i
683
U-1-14-ii
684
U-1-14-iii
685
U-1-15-i
1.338.471
1.378.625
1.405.395
1.432.164
686
U-1-15-ii
1.901.874
1.958.930
1.996.968
2.035.005
687
U-1-15-iii
3.747.719
3.860.151
3.935.105
4.010.060
- 717 No
Kode
INA-CBG
688
U-1-20-i
689
U-1-20-ii
690
U-1-20-iii
691
U-1-30-i
692
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.462.042
3.565.903
3.635.144
3.704.385
6.162.435
6.347.308
6.470.557
6.593.805
15.202.952
15.659.040
15.963.099
16.267.158
2.969.828
3.058.923
3.118.320
3.177.716
U-1-30-ii
4.009.268
4.129.546
4.209.732
4.289.917
693
U-1-30-iii
7.859.319
8.095.098
8.252.284
8.409.471
694
U-4-10-i
2.764.414
2.847.347
2.902.635
2.957.923
695
U-4-10-ii
6.929.806
7.137.700
7.276.296
7.414.892
696
U-4-10-iii
10.109.077
10.412.350
10.614.531
10.816.713
697
U-4-11-i
1.532.986
1.578.975
1.609.635
1.640.295
698
U-4-11-ii
2.299.479
2.368.463
2.414.453
2.460.442
699
U-4-11-iii
3.180.170
3.275.575
3.339.179
3.402.782
700
U-4-12-i
1.532.986
1.578.975
1.609.635
1.640.295
701
U-4-12-ii
1.787.108
1.840.722
1.876.464
1.912.206
702
U-4-12-iii
2.841.421
2.926.664
2.983.492
3.040.321
703
U-4-13-i
1.506.046
1.551.227
1.581.348
1.611.469
704
U-4-13-ii
1.750.866
1.803.392
1.838.409
1.873.427
705
U-4-13-iii
1.987.980
2.047.620
2.087.379
2.127.139
706
U-4-14-i
1.916.232
1.973.719
2.012.044
2.050.369
707
U-4-14-ii
2.299.479
2.368.463
2.414.453
2.460.442
708
U-4-14-iii
3.852.026
3.967.587
4.044.627
4.121.668
709
U-4-15-i
1.532.986
1.578.975
1.609.635
1.640.295
710
U-4-15-ii
1.916.232
1.973.719
2.012.044
2.050.369
711
U-4-15-iii
2.683.245
2.763.743
2.817.408
2.871.073
712
V-1-10-i
4.481.426
4.615.869
4.705.497
4.795.126
713
V-1-10-ii
5.162.664
5.317.544
5.420.798
5.524.051
714
V-1-10-iii
9.809.062
10.103.334
10.299.516
10.495.697
715
V-1-11-i
5.162.664
5.317.544
5.420.798
5.524.051
716
V-1-11-ii
5.761.620
5.934.469
6.049.701
6.164.934
717
V-1-11-iii
8.532.077
8.788.040
8.958.681
9.129.323
2.788.254
2.871.902
2.927.667
2.983.432
10.655.780
10.975.453
11.188.569
11.401.685
12.441.594
12.814.842
13.063.674
13.312.506
718
V-1-12-i
719
V-1-12-ii
720
V-1-12-iii


DAN TELINGA RINGAN
DAN TELINGA SEDANG
DAN TELINGA BERAT


KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

- 718 No
Kode
INA-CBG
721
V-1-13-i
722
V-1-13-ii
723
V-1-13-iii
724
V-1-14-i
725
V-1-14-ii
726
V-1-14-iii
727
V-1-15-i
728
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.226.089
4.352.872
4.437.394
4.521.916
8.030.782
8.271.706
8.432.321
8.592.937
12.390.395
12.762.107
13.009.914
13.257.722
5.094.600
5.247.438
5.349.330
5.451.222
7.409.659
7.631.949
7.780.142
7.928.335
10.072.353
10.374.524
10.575.971
10.777.418
2.401.820
2.473.875
2.521.911
2.569.948
V-1-15-ii
4.575.000
4.712.250
4.803.750
4.895.250
729
V-1-15-iii
8.042.762
8.284.045
8.444.900
8.605.756
730
V-4-10-i
3.867.537
3.983.563
4.060.914
4.138.264
731
V-4-10-ii
4.995.386
5.145.247
5.245.155
5.345.063
732
V-4-10-iii
9.547.059
9.833.470
10.024.412
10.215.353
733
V-4-11-i
1.966.787
2.025.791
2.065.127
2.104.462
734
V-4-11-ii
2.873.790
2.960.004
3.017.480
3.074.956
735
V-4-11-iii
4.741.564
4.883.811
4.978.642
5.073.473
736
W-1-01-i
5.783.318
5.956.817
6.072.484
6.188.150
737
W-1-01-ii
6.965.732
7.174.704
7.314.018
7.453.333
738
W-1-01-iii
15.385.918
15.847.495
16.155.214
16.462.932
739
W-1-10-i
1.610.647
1.658.966
1.691.179
1.723.392
740
W-1-10-ii
3.005.732
3.095.904
3.156.018
3.216.133
741
W-1-10-iii
4.916.423
5.063.916
5.162.244
5.260.573
742
W-1-11-i
1.672.927
1.723.114
1.756.573
1.790.031
743
W-1-11-ii
3.226.451
3.323.244
3.387.773
3.452.302
744
W-1-11-iii
6.195.197
6.381.053
6.504.957
6.628.861
745
W-1-12-i
1.520.105
1.565.708
1.596.111
1.626.513
746
W-1-12-ii
1.728.331
1.780.180
1.814.747
1.849.314
747
W-1-12-iii
2.654.934
2.734.582
2.787.680
2.840.779
748
W-1-13-i
1.809.285
1.863.563
1.899.749
1.935.934
749
W-1-13-ii
1.964.362
2.023.292
2.062.580
2.101.867
750
W-1-13-iii
2.638.500
2.717.655
2.770.425
2.823.195
751
W-1-20-i
4.929.785
5.077.678
5.176.274
5.274.870
752
W-1-20-ii
6.934.482
7.142.517
7.281.206
7.419.896

NON KOMPLEK (BERAT)

RINGAN
SEDANG
BERAT

SERVIK RINGAN
SERVIK SEDANG
SERVIK BERAT
ENDOSKOP RINGAN
ENDOSKOP SEDANG
ENDOSKOP BERAT
- 719 No
Kode
INA-CBG
753
W-1-20-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
8.760.206
9.023.012
9.198.216
9.373.420
2.691.168
2.771.903
2.825.727
2.879.550
4.292.553
4.421.329
4.507.180
4.593.031
11.414.953
11.757.402
11.985.701
12.214.000
754
W-1-30-i
755
W-1-30-ii
756
W-1-30-iii
757
W-4-10-i
2.006.937
2.067.145
2.107.284
2.147.423
758
W-4-10-ii
2.712.601
2.793.979
2.848.231
2.902.483
759
W-4-10-iii
6.131.944
6.315.902
6.438.541
6.561.180
760
W-4-11-i
1.916.232
1.973.719
2.012.044
2.050.369
761
W-4-11-ii
3.065.972
3.157.951
3.219.270
3.280.590
762
W-4-11-iii
3.726.064
3.837.846
3.912.368
3.986.889
1.532.986
1.578.975
1.609.635
1.640.295
2.107.856
2.171.091
2.213.248
2.255.406
2.350.025
2.420.526
2.467.526
2.514.527

763
W-4-12-i
764
W-4-12-ii
765
W-4-12-iii
766
W-4-13-i
ABORTUS RINGAN
840.708
865.929
882.743
899.557
767
W-4-13-ii
ABORTUS SEDANG
1.149.739
1.184.232
1.207.226
1.230.221
768
W-4-13-iii
ABORTUS BERAT
1.532.986
1.578.975
1.609.635
1.640.295
769
W-4-14-i
1.149.739
1.184.232
1.207.226
1.230.221
770
W-4-14-ii
1.478.751
1.523.113
1.552.688
1.582.263
771
W-4-14-iii
1.860.721
1.916.542
1.953.757
1.990.971
772
W-4-15-i
958.749
987.511
1.006.686
1.025.861
773
W-4-15-ii
1.066.311
1.098.301
1.119.627
1.140.953
774
W-4-15-iii
1.476.409
1.520.702
1.550.230
1.579.758
775
W-4-16-i
1.149.739
1.184.232
1.207.226
1.230.221
776
W-4-16-ii
1.532.986
1.578.975
1.609.635
1.640.295
777
W-4-16-iii
2.090.018
2.152.718
2.194.519
2.236.319
778
W-4-17-i
939.056
967.228
986.009
1.004.790
779
W-4-17-ii
1.532.986
1.578.975
1.609.635
1.640.295
780
W-4-17-iii
2.900.104
2.987.108
3.045.110
3.103.112
781
Z-4-10-i
REHABILITASI RINGAN
2.630.422
2.709.335
2.761.943
2.814.552
782
Z-4-10-ii
REHABILITASI SEDANG
3.491.506
3.596.251
3.666.081
3.735.911
783
Z-4-10-iii
REHABILITASI BERAT
4.960.017
5.108.818
5.208.018
5.307.218
784
Z-4-11-i
2.296.069
2.364.951
2.410.873
2.456.794
785
Z-4-11-ii
2.763.960
2.846.879
2.902.158
2.957.437
786
Z-4-11-iii
4.373.076
4.504.268
4.591.730
4.679.191
- 720 No
Kode
INA-CBG
787
Z-4-12-i
788
Z-4-12-ii
789
Z-4-12-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.149.739
1.184.232
1.207.226
1.230.221
2.342.556
2.412.833
2.459.684
2.506.535
2.977.018
3.066.329
3.125.869
3.185.409
- 721 b. RawatJalan
No
Kode
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
775.006
798.256
813.756
829.256
1.005.304
1.035.463
1.055.569
1.075.675
1.869.494
1.925.579
1.962.969
2.000.359
1.544.956
1.591.304
1.622.204
1.653.103
1.290.677
1.329.398
1.355.211
1.381.025
452.517
466.093
475.143
484.193
1.009.054
1.039.326
1.059.507
1.079.688

207.327
213.547
217.694
221.840
C-3-10-0
565.560
582.527
593.838
605.149
10
C-3-11-0

KANDUNG KEMIH
894.454
921.288
939.177
957.066
11
C-3-12-0
202.771
208.854
212.909
216.965
196.904
202.812
206.750
210.688
1.676.251
1.726.538
1.760.063
1.793.588
1.536.351
1.582.441
1.613.168
1.643.895

LAPAROSKOPI
PANKREAS
LAPAROSKOPI
EMPEDU

OVARIUM
GASTROINTESTINAL
GINJAL ATAU PROSTAT
12
C-3-13-0
13
C-3-14-0
14
C-3-15-0
15
C-3-16-0
348.407
358.860
365.828
372.796
16
C-3-17-0

LEHER
231.123
238.057
242.679
247.302
17
C-3-18-0
102.470
105.544
107.594
109.643
18
C-3-19-0

MYELOMA ATAU TESTIS
144.913
149.261
152.159
155.057
19
C-3-20-0
2.885.957
2.972.536
3.030.255
3.087.974
20
C-3-21-0
165.372
170.333
173.641
176.948
21
C-3-22-0
726.072
747.854
762.376
776.897
22
C-3-23-0
117.608
121.136
123.488
125.840
23
D-2-10-0

TULANG
996.390
1.026.282
1.046.209
1.066.137
24
D-2-11-0
PROSEDUR LIMPA
1.247.650
1.285.080
1.310.033
1.334.986
25
D-2-21-0
1.046.425
1.077.818
1.098.747
1.119.675
26
D-2-22-0
229.659
236.549
241.142
245.735
27
D-3-10-0
166.348
171.338
174.665
177.992
28
D-3-11-0
431.886
444.843
453.481
462.118
29
E-2-10-0
256.192
263.877
269.001
274.125
30
E-2-21-0
185.730
191.302
195.017
198.731
31
E-2-22-0
185.730
191.302
195.017
198.731

TYMUS
TYMUS
TULANG
PEMBENTUK DARAH
PARATIROID
THYROGLOSSAL
- 722 No
Kode
INA-CBG
32
E-3-10-0
33
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

ENDOKRIN
215.992
222.472
226.792
231.112
F-3-10-0
TERAPI SHOCK
301.302
310.341
316.367
322.393
34
F-5-10-0
369.193
380.268
387.652
395.036
35
F-5-11-0
TERAPI KELOMPOK
243.449
250.752
255.621
260.490
36
F-5-12-0
311.534
320.880
327.110
333.341
37
F-5-13-0
263.848
271.764
277.041
282.318
38
F-5-14-0
177.007
182.317
185.857
189.397
39
F-5-15-0
166.055
171.037
174.358
177.679
40
F-5-16-0
172.963
178.151
181.611
185.070
41
G-2-10-0
145.648
150.017
152.930
155.843
42
G-2-11-0
1.262.536
1.300.412
1.325.663
1.350.914
43
G-2-12-0

EKSTRAKRANIAL
1.829.726
1.884.618
1.921.212
1.957.807
44
G-2-13-0
448.873
462.339
471.316
480.294
45
G-2-21-0
818.668
843.228
859.601
875.975
46
G-2-22-0
743.011
765.301
780.161
795.022
47
G-2-31-0
1.226.033
1.262.814
1.287.334
1.311.855
48
G-2-32-0
628.463
647.317
659.886
672.456
49
G-3-10-0
249.441
256.924
261.913
266.902
50
G-3-11-0
332.208
342.174
348.818
355.462
51
G-3-12-0
544.328
560.658
571.544
582.431
52
G-3-13-0
544.390
560.722
571.610
582.497
53
H-2-21-0
714.431
735.864
750.153
764.441
54
H-2-22-0
185.730
191.302
195.017
198.731
55
H-2-23-0
185.730
191.302
195.017
198.731
56
H-2-31-0
1.183.396
1.218.898
1.242.565
1.266.233
57
H-2-32-0
123.164
126.859
129.322
131.785
58
H-2-33-0
185.730
191.302
195.017
198.731
59
H-2-34-0
530.900
546.827
557.445
568.063
60
H-2-35-0
174.944
180.192
183.691
187.190
61
H-2-36-0
944.305
972.634
991.520
1.010.406
62
H-2-37-0

1.005.254
1.035.412
1.055.517
1.075.622
63
H-3-10-0
349.755
360.248
367.243
374.238
64
H-3-11-0
183.932
189.450
193.129
196.808

AKUT
MENTAL
PROSEDUR KRANIOTOMI

MATA
MATA
MATA
MATA
MATA
- 723 No
Kode
INA-CBG
65
H-3-12-0
66
H-3-13-0
67
I-2-11-0
68
I-2-12-0
69
I-2-13-0
70
I-2-14-0
71
I-2-15-0
Deskripsi (INA-CBG)
MATA
TORASIK
ABDOMEN
PENGGANTIAN ALAT
DARAH VENA
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
192.035
197.796
201.636
205.477
186.454
192.048
195.777
199.506
2.150.214
2.214.720
2.257.725
2.300.729
1.511.835
1.557.190
1.587.427
1.617.663
1.921.451
1.979.095
2.017.524
2.055.953
3.400.560
3.502.576
3.570.588
3.638.599
204.503
210.638
214.728
218.818
2.147.884
2.212.320
2.255.278
2.298.235
708.096
729.338
743.500
757.662
72
I-2-16-0
73
I-2-17-0
74
I-2-21-0
1.657.861
1.707.597
1.740.754
1.773.911
75
I-2-22-0
1.561.166
1.608.001
1.639.225
1.670.448
76
I-2-23-0
319.488
329.073
335.462
341.852
77
I-2-31-0
2.484.766
2.559.309
2.609.004
2.658.700
78
I-2-32-0
3.249.197
3.346.672
3.411.656
3.476.640
79
I-2-41-0
2.178.626
2.243.985
2.287.558
2.331.130
80
I-2-42-0

LAIN
2.533.013
2.609.004
2.659.664
2.710.324
81
I-3-10-0
PROSEDUR RESUSITASI
321.544
331.190
337.621
344.052
82
I-3-11-0
169.710
174.801
178.195
181.590
83
I-3-12-0
986.290
1.015.879
1.035.605
1.055.331
84
I-3-13-0
323.936
333.654
340.133
346.611
85
I-3-14-0
207.632
213.861
218.013
222.166
183.932
189.450
193.129
196.808
1.138.791
1.172.955
1.195.730
1.218.506
183.573
189.080
192.752
196.423
925.093
952.845
971.347
989.849
1.199.928
1.235.926
1.259.924
1.283.923

PACU JANTUNG

KARDIOVASKULAR
PERNAFASAN
PENDEK
86
I-3-15-0
87
J-2-10-0
88
J-2-21-0
89
J-2-22-0
90
J-2-31-0
PROSEDUR
91
J-2-32-0
892.945
919.734
937.593
955.452
92
J-3-10-0
185.730
191.302
195.017
198.731
93
J-3-11-0

PADA DADA
524.840
540.586
551.082
561.579
94
J-3-12-0
202.771
208.854
212.909
216.965
95
J-3-13-0
298.428
307.381
313.350
319.318
96
J-3-14-0
316.814
326.318
332.655
338.991
- 724 No
Kode
INA-CBG
97
J-3-15-0
98
J-3-16-0
99
J-3-17-0
100
K-2-10-0
101
K-2-11-0
102
K-2-12-0

103
K-2-13-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
277.821
286.155
291.712
297.268
316.814
326.318
332.655
338.991
185.730
191.302
195.017
198.731
534.595
550.633
561.325
572.017
1.141.578
1.175.826
1.198.657
1.221.489
876.309
902.598
920.124
937.650
1.426.240
1.469.027
1.497.552
1.526.077
185.730
191.302
195.017
198.731
185.730
191.302
195.017
198.731
2.387.075
2.458.687
2.506.429
2.554.170
802.652
826.732
842.785
858.838
185.730
191.302
195.017
198.731

PERNAFASAN
KECIL

FEMORALIS
USUS BESAR
ATAS
ATAS
104
K-2-14-0
105
K-2-21-0
106
K-2-22-0
107
K-2-31-0
108
K-2-32-0
109
K-2-41-0
884.138
910.662
928.345
946.027
110
K-2-42-0

252.609
260.187
265.240
270.292
111
K-2-51-0
585.883
603.460
615.177
626.895
112
K-2-52-0
319.488
329.073
335.462
341.852
113
K-2-53-0
185.730
191.302
195.017
198.731
114
K-3-10-0

GASTROINTESTINAL
353.432
364.035
371.104
378.172
115
K-3-11-0
212.482
218.856
223.106
227.355
116
K-3-12-0
215.483
221.948
226.257
230.567
117
K-3-13-0
185.730
191.302
195.017
198.731
497.761
512.694
522.649
532.604
240.376
247.587
252.394
257.202
318.513
328.068
334.439
340.809
1.095.060
1.127.911
1.149.813
1.171.714
701.925
722.983
737.022
751.060
316.814
326.318
332.655
338.991
319.488
329.073
335.462
341.852

GASTROINTESTINAL
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
118
K-3-14-0
119
K-3-15-0
120
K-3-16-0
121
L-2-21-0
122
L-2-22-0
123
L-2-31-0
124
L-2-32-0
125
L-2-41-0
956.669
985.369
1.004.502
1.023.636
126
L-2-42-0

214.565
221.002
225.294
229.585
127
L-2-51-0
1.432.283
1.475.252
1.503.897
1.532.543
L-2-52-0

1.095.744
1.128.616
1.150.531
1.172.446
128
- 725 No
Kode
INA-CBG
129
L-2-53-0
130
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

185.730
191.302
195.017
198.731
L-3-10-0
252.609
260.187
265.240
270.292
131
L-3-11-0
245.301
252.660
257.566
262.472
132
L-3-12-0
186.820
192.425
196.161
199.897
133
M-2-10-0
1.465.330
1.509.290
1.538.597
1.567.903
134
M-2-21-0
1.312.305
1.351.674
1.377.920
1.404.166
135
M-2-22-0
319.488
329.073
335.462
341.852
136
M-2-31-0
PROSEDUR BUNION
797.093
821.006
836.948
852.890
137
M-2-32-0
252.609
260.187
265.240
270.292
138
M-2-41-0

TULANG
252.609
260.187
265.240
270.292
139
M-2-42-0
87.056
89.668
91.409
93.150
140
M-2-51-0
185.730
191.302
195.017
198.731
141
M-2-52-0
185.730
191.302
195.017
198.731
142
M-2-61-0
PROSEDUR ARTROSKOPI
910.361
937.672
955.879
974.086
143
M-2-62-0
185.730
191.302
195.017
198.731
915.285
942.744
961.050
979.355
1.248.260
1.285.708
1.310.673
1.335.639
185.730
191.302
195.017
198.731
921.544
949.191
967.621
986.052
889.329
916.009
933.796
951.583

DAN WAJAH
PAHA
PAHA

TULANG
WAJAH
WAJAH
BAWAH
BAWAH
144
M-2-63-0
145
M-2-64-0
146
M-2-65-0
147
M-2-71-0
148
M-2-72-0
149
M-2-81-0
1.326.180
1.365.965
1.392.489
1.419.012
150
M-2-82-0
963.384
992.286
1.011.554
1.030.821
151
M-2-83-0
185.730
191.302
195.017
198.731
152
M-2-84-0
185.730
191.302
195.017
198.731
153
M-3-10-0
530.110
546.013
556.615
567.217
154
M-3-11-0
293.914
302.731
308.609
314.487
155
M-3-12-0
664.663
684.603
697.896
711.189
156
M-3-13-0
216.698
223.199
227.533
231.867
157
M-3-14-0

TERTUTUP
370.374
381.485
388.892
396.300
158
M-3-15-0
163.172
168.067
171.331
174.594
159
M-3-16-0

185.730
191.302
195.017
198.731
160
M-3-17-0
202.771
208.854
212.909
216.965
161
N-2-11-0
2.453.678
2.527.288
2.576.362
2.625.435

PERGELANGAN TANGAN
PERGELANGAN TANGAN
MUSKULOSKELETAL
SKELETAL
- 726 No
Kode
INA-CBG
162
N-2-12-0
163
N-2-21-0
164
N-2-22-0
165
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.419.428
1.462.011
1.490.400
1.518.788
1.411.946
1.454.305
1.482.544
1.510.783
319.488
329.073
335.462
341.852
N-2-23-0
319.488
329.073
335.462
341.852
166
N-2-24-0
1.032.478
1.063.452
1.084.102
1.104.751
167
N-2-31-0
869.179
895.254
912.638
930.022
168
N-2-32-0
319.488
329.073
335.462
341.852
169
N-2-41-0
319.488
329.073
335.462
341.852
170
N-2-42-0
540.315
556.525
567.331
578.138
171
N-3-10-0
319.488
329.073
335.462
341.852
172
N-3-11-0
370.172
381.278
388.681
396.085
173
N-3-12-0
286.049
294.630
300.351
306.072
174
N-3-13-0
319.488
329.073
335.462
341.852
175
N-3-14-0
274.902
283.149
288.647
294.145
176
N-3-15-0
704.918
726.066
740.164
754.262
177
O-7-10-0
117.691
121.222
123.575
125.929
178
O-7-11-0
648.155
667.600
680.563
693.526
179
O-7-12-0
236.015
243.096
247.816
252.536
180
O-7-13-0
131.167
135.102
137.725
140.348
181
P-9-10-0
174.944
180.192
183.691
187.190
182
P-9-11-0
174.944
180.192
183.691
187.190
183
P-9-12-0
174.944
180.192
183.691
187.190
184
P-9-13-0
174.944
180.192
183.691
187.190
185
P-9-14-0
174.944
180.192
183.691
187.190
186
P-9-15-0
111.513
114.858
117.088
119.319
187
P-9-16-0
174.944
180.192
183.691
187.190
188
P-9-17-0
174.191
179.417
182.901
186.385
189
Q-5-10-0
228.007
234.848
239.408
243.968
190
Q-5-11-0
170.885
176.012
179.430
182.847
191
Q-5-12-0
GIGI
150.614
155.132
158.144
161.157
192
Q-5-13-0
MEDICAL CHECK-UP
114.460
117.894
120.183
122.472
193
Q-5-14-0
125.943
129.722
132.240
134.759


DAN URETHRA
DAN URETHRA
TRANSURETHRA
TRANSURETHRA
SALURAN KEMIH
KEMIH
KEMIH
PROSEDUR DIALISIS
CAESAR
VAGINAL/JALAN LAHIR

ASPIRASI
- 727 No
Kode
INA-CBG
194
Q-5-15-0
195
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
86.611
89.209
90.942
92.674
Q-5-16-0
VAKSINASI
97.891
100.827
102.785
104.743
196
Q-5-17-0
PASANG INFUS
84.673
87.213
88.906
90.600
197
Q-5-18-0
159.381
164.162
167.350
170.537
198
Q-5-19-0
178.178
183.523
187.087
190.651
199
Q-5-20-0
ABORSI MENGANCAM
119.427
123.010
125.398
127.787
200
Q-5-21-0
ABORSI
117.800
121.334
123.690
126.046
201
Q-5-22-0
125.943
129.722
132.240
134.759
202
Q-5-23-0
154.188
158.813
161.897
164.981
203
Q-5-24-0
105.308
108.467
110.573
112.680
204
Q-5-25-0
164.226
169.153
172.437
175.722
205
Q-5-26-0
BRONKIAL AKUT
232.450
239.424
244.073
248.722
206
Q-5-27-0
165.423
170.386
173.694
177.003
207
Q-5-28-0
134.236
138.264
140.948
143.633
208
Q-5-29-0

JANTUNG LAIN-LAIN
380.046
391.447
399.048
406.649
209
Q-5-30-0
440.432
453.645
462.453
471.262
210
Q-5-31-0
FRAKTUR
157.128
161.842
164.985
168.127
211
Q-5-32-0
SALURAN KEMIH AKUT
181.990
187.450
191.090
194.729
212
Q-5-33-0
HEMATOLOGI AKUT
190.543
196.259
200.070
203.881
213
Q-5-34-0
INFEKSI VIRUS HIV
270.680
278.800
284.214
289.627
214
Q-5-35-0
INFEKSI AKUT
306.943
316.152
322.291
328.430
215
Q-5-36-0
357.456
368.179
375.328
382.477
216
Q-5-37-0

SHOCK
182.321
187.790
191.437
195.083
217
Q-5-38-0
PARU AKUT
243.130
250.424
255.287
260.150
218
Q-5-39-0
155.586
160.253
163.365
166.477
219
Q-5-40-0
152.654
157.234
160.287
163.340
220
Q-5-41-0
211.328
217.668
221.895
226.121
221
Q-5-42-0
165.690
170.660
173.974
177.288
222
Q-5-43-0
238.603
245.761
250.533
255.305
223
Q-5-44-0
194.733
200.575
204.470
208.364
224
T-2-10-0

TERAPI DETOKSIKASI
101.005
104.035
106.055
108.075
225
U-2-10-0
1.348.022
1.388.463
1.415.423
1.442.384
226
U-2-11-0

LEHER
1.602.274
1.650.343
1.682.388
1.714.434
227
U-2-12-0
176.292
181.581
185.107
188.632
- 728 No
Kode
INA-CBG
228
U-2-13-0
229
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
231.123
238.057
242.679
247.302
U-2-14-0
429.322
442.202
450.788
459.375
230
U-2-15-0
243.931
251.249
256.128
261.007
231
U-2-21-0
284.142
292.666
298.349
304.032
232
U-2-22-0
548.985
565.455
576.434
587.414
233
U-2-23-0
719.348
740.928
755.315
769.702
234
U-2-24-0
606.254
624.442
636.567
648.692
235
U-2-25-0
231.123
238.057
242.679
247.302
236
U-2-31-0
185.730
191.302
195.017
198.731
237
U-2-32-0
231.123
238.057
242.679
247.302
238
U-3-10-0
220.966
227.595
232.014
236.434
239
U-3-11-0
234.597
241.635
246.327
251.019
240
U-3-12-0
103.738
106.851
108.925
111.000
241
U-3-13-0
228.025
234.866
239.427
243.987
242
U-3-14-0
209.508
215.793
219.984
224.174
243
U-3-15-0
182.710
188.191
191.845
195.499
244
U-3-16-0
PROSEDUR PADA GIGI
206.063
212.245
216.367
220.488
245
V-2-10-0

PROSTAT
2.010.387
2.070.699
2.110.907
2.151.114
246
V-2-11-0
226.721
233.522
238.057
242.591
723.497
745.202
759.672
774.142
319.488
329.073
335.462
341.852
319.488
329.073
335.462
341.852

(RHINOPLASTY)

RONGGA HIDUNG
TENGGOROKAN
PROSEDUR PADA PENIS

SKROTUM
SKROTUM
TRANSURETHRAL
247
V-2-12-0
248
V-2-13-0
249
V-2-14-0
250
V-2-15-0
SIRKUMSISI/SUNAT
174.944
180.192
183.691
187.190
251
V-3-10-0
364.857
375.802
383.100
390.397
252
V-3-11-0
771.861
795.017
810.454
825.891
253
V-3-12-0
445.616
458.984
467.897
476.809
254
W-2-10-0
163.172
168.067
171.331
174.594
255
W-2-11-0
417.007
429.518
437.858
446.198
256
W-2-12-0
771.861
795.017
810.454
825.891
257
W-2-13-0
123.793
127.507
129.982
132.458
258
W-2-21-0
1.551.647
1.598.196
1.629.229
1.660.262
259
W-2-22-0
163.172
168.067
171.331
174.594

PROSEDUR ABORSI
RAHIM & LEHER RAHIM
TERHALANG/TERGANGGU
TERHALANG/TERGANGGU
PANGGUL TERBUKA
PANGGUL TERBUKA
- 729 No
Kode
INA-CBG
260
W-2-23-0
Deskripsi (INA-CBG)
JALAN LAHIR
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
544.514
560.849
571.739
582.630
1.787.473
1.841.097
1.876.846
1.912.596
1.253.636
1.291.245
1.316.317
1.341.390
261
W-2-31-0
262
W-2-32-0
263
W-2-33-0
532.812
548.796
559.452
570.109
264
W-2-34-0
181.219
186.655
190.280
193.904
265
W-3-10-0
440.431
453.644
462.453
471.262
266
W-3-11-0
352.068
362.630
369.672
376.713
267
W-3-12-0
163.172
168.067
171.331
174.594
268
Z-3-10-0
1.847.327
1.902.747
1.939.693
1.976.640
269
Z-3-11-0

EMPEDU
1.411.946
1.454.305
1.482.544
1.510.783
270
Z-3-12-0
235.761
242.834
247.549
252.264
271
Z-3-13-0

LAIN-LAIN
1.438.678
1.481.838
1.510.611
1.539.385
272
Z-3-14-0
DIAGNOSTIK TIDUR
284.471
293.005
298.695
304.384
273
Z-3-15-0
185.730
191.302
195.017
198.731
274
Z-3-16-0

(MRI)
596.137
614.022
625.944
637.867
275
Z-3-17-0
PENGOBATAN NUKLIR
250.271
257.780
262.785
267.790
276
Z-3-18-0
CT-SCAN KEPALA
241.132
248.366
253.188
258.011
277
Z-3-19-0
CT SCAN LAIN-LAIN
250.971
258.500
263.520
268.539
278
Z-3-20-0
170.692
175.812
179.226
182.640
279
Z-3-21-0
163.172
168.067
171.331
174.594
280
Z-3-22-0
183.962
189.481
193.160
196.839
281
Z-3-23-0
191.612
197.361
201.193
205.025
282
Z-3-24-0
376.480
387.775
395.304
402.834
283
Z-3-25-0
167.684
172.714
176.068
179.422
284
Z-3-26-0
189.516
195.201
198.992
202.782
285
Z-3-27-0
PERAWATAN LUKA
180.936
186.364
189.983
193.602
286
Z-3-28-0
IMAGING PAYUDARA
185.730
191.302
195.017
198.731
287
Z-3-29-0
IMAGING LAIN-LAIN
535.308
551.367
562.073
572.779
288
Z-3-30-0
FOTOTERAPI
90.340
93.050
94.857
96.664
- 730 3. RUMAH SAKIT MATAKELAS C

a. RawatInap
No
Kode
INA-CBG
A-4-10-i
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
SEPTIKEMIA RINGAN
2.174.376
2.239.607
2.283.095
2.326.582
A-4-10-ii
SEPTIKEMIA SEDANG
2.489.076
2.563.749
2.613.530
2.663.312
A-4-10-iii
SEPTIKEMIA BERAT
3.902.402
4.019.474
4.097.522
4.175.570
A-4-11-i
3.907.861
4.025.097
4.103.254
4.181.412
A-4-11-ii

SEDANG
6.037.194
6.218.310
6.339.054
6.459.798
A-4-11-iii
9.875.531
10.171.797
10.369.307
10.566.818
A-4-12-i
DEMAM RINGAN
1.532.986
1.578.975
1.609.635
1.640.295
A-4-12-ii
DEMAM SEDANG
2.198.736
2.264.699
2.308.673
2.352.648
A-4-12-iii
DEMAM BERAT
2.516.293
2.591.781
2.642.107
2.692.433
10
A-4-13-i
1.916.232
1.973.719
2.012.044
2.050.369
11
A-4-13-ii
2.299.479
2.368.463
2.414.453
2.460.442
12
A-4-13-iii
2.794.745
2.878.587
2.934.482
2.990.377
13
A-4-14-i
1.532.986
1.578.975
1.609.635
1.640.295
14
A-4-14-ii
2.434.702
2.507.743
2.556.437
2.605.131
15
A-4-14-iii
2.772.448
2.855.621
2.911.070
2.966.519
16
A-4-15-i
INFEKSI HIV RINGAN
2.299.479
2.368.463
2.414.453
2.460.442
17
A-4-15-ii
INFEKSI HIV SEDANG
3.449.218
3.552.695
3.621.679
3.690.664
18
A-4-15-iii
INFEKSI HIV BERAT
4.797.050
4.940.962
5.036.903
5.132.844
19
B-1-01-i
25.493.308
26.258.107
26.767.974
27.277.840
20
B-1-01-ii
28.125.935
28.969.713
29.532.231
30.094.750
21
B-1-01-iii
49.338.677
50.818.837
51.805.611
52.792.384
22
B-1-10-i
3.305.121
3.404.275
3.470.377
3.536.479
23
B-1-10-ii
8.423.040
8.675.731
8.844.192
9.012.653
24
B-1-10-iii
14.661.180
15.101.015
15.394.239
15.687.463
25
B-1-11-i
2.259.482
2.327.266
2.372.456
2.417.646
26
B-1-11-ii
5.671.513
5.841.658
5.955.088
6.068.519
27
B-1-11-iii
7.110.670
7.323.990
7.466.203
7.608.416
28
B-1-12-i
4.819.556
4.964.143
5.060.534
5.156.925
29
B-1-12-ii
10.329.488
10.639.373
10.845.963
11.052.553
30
B-1-12-iii
12.571.377
12.948.518
13.199.945
13.451.373

LAIN-LAIN RINGAN
LAIN-LAIN SEDANG
LAIN-LAIN BERAT

(RINGAN)
(SEDANG)
(BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT
- 731 No
Kode
INA-CBG
31
B-1-13-i
32
B-1-13-ii
33
B-1-13-iii
34
B-1-14-i
35
B-1-14-ii
36
B-1-14-iii
37
B-4-10-i
38
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.158.148
3.252.892
3.316.055
3.379.218
5.144.165
5.298.490
5.401.373
5.504.256
7.583.942
7.811.461
7.963.140
8.114.818
4.288.543
4.417.199
4.502.970
4.588.741
4.769.725
4.912.817
5.008.211
5.103.606
7.461.668
7.685.518
7.834.751
7.983.985
1.199.364
1.235.345
1.259.332
1.283.320
B-4-10-ii
1.916.232
1.973.719
2.012.044
2.050.369
39
B-4-10-iii
2.929.692
3.017.583
3.076.176
3.134.770
40
B-4-11-i
2.896.934
2.983.842
3.041.780
3.099.719
41
B-4-11-ii
4.404.062
4.536.184
4.624.266
4.712.347
42
B-4-11-iii
4.743.328
4.885.628
4.980.495
5.075.361
43
B-4-12-i
2.541.861
2.618.117
2.668.954
2.719.791
44
B-4-12-ii
3.603.733
3.711.845
3.783.920
3.855.994
45
B-4-12-iii
7.004.179
7.214.304
7.354.388
7.494.471
46
B-4-13-i
2.299.479
2.368.463
2.414.453
2.460.442
47
B-4-13-ii
3.588.463
3.696.117
3.767.886
3.839.655
48
B-4-13-iii
5.446.525
5.609.921
5.718.852
5.827.782
49
B-4-14-i
2.299.479
2.368.463
2.414.453
2.460.442
50
B-4-14-ii
2.682.725
2.763.207
2.816.862
2.870.516
51
B-4-14-iii
3.579.026
3.686.396
3.757.977
3.829.557
52
C-4-10-i
2.239.228
2.306.405
2.351.190
2.395.974
53
C-4-10-ii
4.350.586
4.481.103
4.568.115
4.655.127
54
C-4-10-iii
LEUKEMIA AKUT BERAT
7.281.683
7.500.134
7.645.767
7.791.401
55
C-4-11-i
2.299.479
2.368.463
2.414.453
2.460.442
56
C-4-11-ii
3.065.972
3.157.951
3.219.270
3.280.590
57
C-4-11-iii
5.212.511
5.368.886
5.473.137
5.577.387
58
C-4-12-i
RADIOTERAPI RINGAN
1.532.986
1.578.975
1.609.635
1.640.295
59
C-4-12-ii
RADIOTERAPI SEDANG
4.220.773
4.347.396
4.431.812
4.516.227
60
C-4-12-iii
RADIOTERAPI BERAT
8.569.015
8.826.086
8.997.466
9.168.846
61
C-4-13-i
KEMOTERAPI RINGAN
1.532.986
1.578.975
1.609.635
1.640.295
62
C-4-13-ii
KEMOTERAPI SEDANG
3.065.972
3.157.951
3.219.270
3.280.590
63
C-4-13-iii
KEMOTERAPI BERAT
4.011.597
4.131.945
4.212.177
4.292.409

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT

PANCREAS RINGAN
PANCREAS SEDANG
PANCREAS BERAT
(RINGAN)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT
- 732 No
Kode
INA-CBG
64
C-4-14-i
65
C-4-14-ii
66
C-4-14-iii
67
D-1-10-i
68
D-1-10-ii
69
D-1-10-iii
70
D-1-11-i
71
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.987.873
2.047.509
2.087.266
2.127.024
2.904.806
2.991.951
3.050.047
3.108.143
4.428.293
4.561.142
4.649.708
4.738.274
16.312.788
16.802.172
17.128.428
17.454.683
24.845.628
25.590.997
26.087.909
26.584.822
33.672.615
34.682.793
35.356.245
36.029.698
3.352.953
3.453.542
3.520.601
3.587.660
D-1-11-ii
8.745.118
9.007.471
9.182.374
9.357.276
72
D-1-11-iii
12.390.395
12.762.107
13.009.914
13.257.722
73
D-1-20-i
4.130.132
4.254.036
4.336.638
4.419.241
74
D-1-20-ii
9.292.796
9.571.580
9.757.436
9.943.292
75
D-1-20-iii
16.798.267
17.302.215
17.638.181
17.974.146
76
D-4-10-i
1.472.527
1.516.703
1.546.153
1.575.604
77
D-4-10-ii
2.973.309
3.062.509
3.121.975
3.181.441
78
D-4-10-iii
3.832.465
3.947.439
4.024.088
4.100.737
79
D-4-11-i
3.353.407
3.454.009
3.521.077
3.588.145
80
D-4-11-ii
5.993.440
6.173.243
6.293.112
6.412.981
81
D-4-11-iii
8.205.378
8.451.540
8.615.647
8.779.755
82
D-4-12-i
1.965.689
2.024.660
2.063.973
2.103.287
83
D-4-12-ii
2.726.604
2.808.402
2.862.934
2.917.466
84
D-4-12-iii
4.186.701
4.312.302
4.396.036
4.479.770
85
D-4-13-i
1.532.986
1.578.975
1.609.635
1.640.295
86
D-4-13-ii
2.299.479
2.368.463
2.414.453
2.460.442
87
D-4-13-iii
2.682.725
2.763.207
2.816.862
2.870.516
88
D-4-14-i
1.847.061
1.902.473
1.939.414
1.976.355
89
D-4-14-ii
4.312.436
4.441.809
4.528.058
4.614.306
90
D-4-14-iii
5.144.139
5.298.463
5.401.346
5.504.229
91
E-1-01-i
3.674.729
3.784.971
3.858.466
3.931.960
92
E-1-01-ii
4.813.546
4.957.952
5.054.223
5.150.494
93
E-1-01-iii
10.910.013
11.237.313
11.455.514
11.673.714
94
E-1-10-i
3.744.352
3.856.683
3.931.570
4.006.457
95
E-1-10-ii
4.544.765
4.681.108
4.772.003
4.862.898
96
E-1-10-iii
9.579.026
9.866.397
10.057.978
10.249.558

RINGAN
SEDANG
BERAT
TULANG RINGAN
TULANG SEDANG
TULANG BERAT


RINGAN
SEDANG
BERAT
- 733 No
Kode
INA-CBG
97
E-1-20-i
98
E-1-20-ii
99
E-1-20-iii
100
E-4-10-i
101
E-4-10-ii
102
E-4-10-iii
103
E-4-11-i
104
E-4-11-ii
105
E-4-11-iii
106
E-4-12-i
107
E-4-12-ii
108
E-4-12-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.336.038
4.466.119
4.552.840
4.639.560
5.807.422
5.981.644
6.097.793
6.213.941
12.867.606
13.253.634
13.510.986
13.768.338
1.916.232
1.973.719
2.012.044
2.050.369
2.725.286
2.807.044
2.861.550
2.916.056
5.209.330
5.365.610
5.469.797
5.573.983
1.634.947
1.683.995
1.716.694
1.749.393
3.093.039
3.185.830
3.247.691
3.309.552
5.100.564
5.253.581
5.355.592
5.457.603
1.953.533
2.012.139
2.051.210
2.090.281
3.393.655
3.495.465
3.563.338
3.631.211
5.541.579
5.707.827
5.818.658
5.929.490
2.060.595
2.122.413
2.163.625
2.204.837
3.538.056
3.644.198
3.714.959
3.785.720
6.121.731
6.305.383
6.427.818
6.550.252

RINGAN
SEDANG
BERAT

RINGAN
SEDANG
BERAT
109
E-4-13-i
110
E-4-13-ii
111
E-4-13-iii
112
F-4-10-i
SCHIZOFRENIA RINGAN
2.519.467
2.595.051
2.645.441
2.695.830
113
F-4-10-ii
SCHIZOFRENIA SEDANG
2.797.950
2.881.888
2.937.847
2.993.806
114
F-4-10-iii
SCHIZOFRENIA BERAT
4.142.426
4.266.699
4.349.547
4.432.396
115
F-4-11-i
2.322.339
2.392.009
2.438.456
2.484.902
116
F-4-11-ii
2.705.745
2.786.917
2.841.032
2.895.147
117
F-4-11-iii
DEPRESI MAYOR BERAT
3.469.754
3.573.847
3.643.242
3.712.637
1.149.739
1.184.232
1.207.226
1.230.221
1.641.665
1.690.915
1.723.748
1.756.581
3.561.316
3.668.156
3.739.382
3.810.609

IMPULSE RINGAN
IMPULSE SEDANG
IMPULSE BERAT
118
F-4-12-i
119
F-4-12-ii
120
F-4-12-iii
121
F-4-13-i
1.876.802
1.933.107
1.970.643
2.008.179
122
F-4-13-ii
2.485.369
2.559.930
2.609.637
2.659.345
123
F-4-13-iii
3.204.566
3.300.703
3.364.794
3.428.885
124
F-4-14-i
DEPRESI RINGAN
1.313.762
1.353.175
1.379.450
1.405.725
125
F-4-14-ii
DEPRESI SEDANG
1.685.166
1.735.721
1.769.424
1.803.127
126
F-4-14-iii
DEPRESI BERAT
2.267.466
2.335.490
2.380.839
2.426.188
127
F-4-15-i
1.561.988
1.608.848
1.640.087
1.671.327
128
F-4-15-ii
2.299.479
2.368.463
2.414.453
2.460.442
129
F-4-15-iii
3.028.555
3.119.411
3.179.982
3.240.554
- 734 No
Kode
INA-CBG
130
F-4-16-i
131
F-4-16-ii
132
F-4-16-iii
133
F-4-17-i
134
F-4-17-ii
135
F-4-17-iii
136
F-4-18-i
137
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.364.216
3.465.143
3.532.427
3.599.712
3.910.817
4.028.142
4.106.358
4.184.575
5.220.288
5.376.897
5.481.303
5.585.708
776.758
800.060
815.596
831.131
2.276.603
2.344.901
2.390.433
2.435.965
2.428.968
2.501.837
2.550.416
2.598.996
2.915.989
3.003.469
3.061.789
3.120.109
F-4-18-ii
3.208.412
3.304.664
3.368.833
3.433.001
138
F-4-18-iii
4.946.047
5.094.428
5.193.349
5.292.270
139
F-4-19-i
2.236.289
2.303.377
2.348.103
2.392.829
140
F-4-19-ii
2.863.625
2.949.534
3.006.807
3.064.079
141
F-4-19-iii
3.565.252
3.672.209
3.743.514
3.814.819
142
G-1-01-i
7.109.639
7.322.928
7.465.121
7.607.314
143
G-1-01-ii
12.033.921
12.394.938
12.635.617
12.876.295
144
G-1-01-iii
23.296.327
23.995.216
24.461.143
24.927.069
145
G-1-10-i
3.548.069
3.654.511
3.725.472
3.796.433
146
G-1-10-ii
5.008.991
5.159.260
5.259.440
5.359.620
147
G-1-10-iii
5.936.724
6.114.826
6.233.560
6.352.294
148
G-1-11-i
4.092.803
4.215.587
4.297.443
4.379.299
149
G-1-11-ii
8.404.879
8.657.026
8.825.123
8.993.221
150
G-1-11-iii
17.599.053
18.127.024
18.479.005
18.830.986
151
G-1-12-i
3.182.995
3.278.485
3.342.145
3.405.804
152
G-1-12-ii
7.287.150
7.505.764
7.651.507
7.797.250
153
G-1-12-iii
12.852.934
13.238.522
13.495.581
13.752.639
154
G-1-13-i
839.455
864.639
881.428
898.217
155
G-1-13-ii
2.254.684
2.322.324
2.367.418
2.412.512
156
G-1-13-iii
5.087.516
5.240.142
5.341.892
5.443.642
4.010.844
4.131.169
4.211.386
4.291.603
5.418.782
5.581.345
5.689.721
5.798.097
13.267.250
13.665.268
13.930.613
14.195.958

RINGAN
SEDANG
BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

RINGAN
SEDANG
BERAT
157
G-1-20-i
158
G-1-20-ii
159
G-1-20-iii
160
G-1-30-i
5.115.471
5.268.935
5.371.244
5.473.554
161
G-1-30-ii
13.351.869
13.752.425
14.019.463
14.286.500
162
G-1-30-iii
17.187.982
17.703.621
18.047.381
18.391.140
- 735 No
Kode
INA-CBG
163
G-4-10-i
164
G-4-10-ii
165
G-4-10-iii
166
G-4-11-i
167
G-4-11-ii
168
G-4-11-iii
169
G-4-12-i
170
G-4-12-ii
171
G-4-12-iii
172
G-4-13-i
173
G-4-13-ii
174
G-4-13-iii
175
G-4-14-i
176
G-4-14-ii
177
G-4-14-iii
178
G-4-15-i
179
G-4-15-ii
180
G-4-15-iii
181
G-4-16-i
182
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.299.479
2.368.463
2.414.453
2.460.442
2.682.725
2.763.207
2.816.862
2.870.516
4.098.460
4.221.414
4.303.383
4.385.353
3.793.975
3.907.795
3.983.674
4.059.554
4.401.011
4.533.042
4.621.062
4.709.082
6.449.758
6.643.251
6.772.246
6.901.241
2.837.560
2.922.686
2.979.438
3.036.189
3.575.325
3.682.585
3.754.091
3.825.598
5.192.734
5.348.516
5.452.371
5.556.226
1.578.799
1.626.163
1.657.739
1.689.315
2.682.725
2.763.207
2.816.862
2.870.516
3.171.362
3.266.503
3.329.930
3.393.358
2.887.388
2.974.010
3.031.758
3.089.506
4.750.728
4.893.250
4.988.265
5.083.279
5.948.020
6.126.461
6.245.421
6.364.381
2.955.326
3.043.986
3.103.092
3.162.199
3.571.068
3.678.200
3.749.622
3.821.043
4.412.866
4.545.252
4.633.510
4.721.767
1.916.232
1.973.719
2.012.044
2.050.369
G-4-16-ii
2.865.743
2.951.715
3.009.030
3.066.345
183
G-4-16-iii
5.200.811
5.356.836
5.460.852
5.564.868
184
G-4-17-i
2.738.471
2.820.625
2.875.395
2.930.164
185
G-4-17-ii
3.398.563
3.500.520
3.568.492
3.636.463
186
G-4-17-iii
5.696.020
5.866.901
5.980.821
6.094.742
187
G-4-18-i
2.299.479
2.368.463
2.414.453
2.460.442
188
G-4-18-ii
3.297.055
3.395.966
3.461.907
3.527.848
189
G-4-18-iii
3.492.894
3.597.681
3.667.538
3.737.396
190
G-4-19-i
1.916.232
1.973.719
2.012.044
2.050.369
191
G-4-19-ii
3.883.503
4.000.008
4.077.678
4.155.348

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
DEGENERATIF RINGAN
DEGENERATIF SEDANG
DEGENERATIF BERAT
RINGAN
SEDANG
BERAT
TRAUMATIK RINGAN
TRAUMATIK SEDANG
TRAUMATIK BERAT
DENGAN INFARK BERAT
TANPA INFARK RINGAN
TANPA INFARK SEDANG
TANPA INFARK BERAT

PERIFER RINGAN
PERIFER SEDANG
PERIFER BERAT
PERSARAFAN RINGAN
PERSARAFAN SEDANG
PERSARAFAN BERAT
RINGAN
SEDANG
- 736 No
Kode
INA-CBG
192
G-4-19-iii
193
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

5.792.953
5.966.742
6.082.601
6.198.460
G-4-20-i
1.341.363
1.381.604
1.408.431
1.435.258
194
G-4-20-ii
1.904.736
1.961.879
1.999.973
2.038.068
195
G-4-20-iii
3.248.022
3.345.463
3.410.423
3.475.383
196
G-4-21-i
1.554.333
1.600.963
1.632.049
1.663.136
197
G-4-21-ii
3.219.178
3.315.754
3.380.137
3.444.521
198
G-4-21-iii
3.792.572
3.906.349
3.982.200
4.058.052
199
G-4-22-i
1.532.986
1.578.975
1.609.635
1.640.295
200
G-4-22-ii
1.916.232
1.973.719
2.012.044
2.050.369
201
G-4-22-iii
2.198.419
2.264.372
2.308.340
2.352.309
202
G-4-23-i
1.532.986
1.578.975
1.609.635
1.640.295
203
G-4-23-ii
1.916.232
1.973.719
2.012.044
2.050.369
204
G-4-23-iii
2.739.118
2.821.292
2.876.074
2.930.857
205
G-4-24-i
1.532.986
1.578.975
1.609.635
1.640.295
206
G-4-24-ii
1.916.232
1.973.719
2.012.044
2.050.369
207
G-4-24-iii
TRAUMA KEPALA BERAT
4.026.755
4.147.558
4.228.093
4.308.628
208
G-4-25-i
GEGAR OTAK RINGAN
1.456.636
1.500.335
1.529.468
1.558.600
209
G-4-25-ii
GEGAR OTAK SEDANG
1.833.937
1.888.955
1.925.634
1.962.312
210
G-4-25-iii
GEGAR OTAK BERAT
2.392.780
2.464.564
2.512.419
2.560.275
211
G-4-26-i
2.299.479
2.368.463
2.414.453
2.460.442
212
G-4-26-ii
2.682.725
2.763.207
2.816.862
2.870.516
213
G-4-26-iii
5.120.947
5.274.576
5.376.995
5.479.414
214
H-1-20-i
1.987.612
2.047.240
2.086.993
2.126.745
215
H-1-20-ii
3.624.635
3.733.375
3.805.867
3.878.360
216
H-1-20-iii
4.929.278
5.077.156
5.175.742
5.274.327
1.946.061
2.004.443
2.043.365
2.082.286
2.218.510
2.285.065
2.329.436
2.373.806

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)

RINGAN
SEDANG
217
H-1-30-i
218
H-1-30-ii
219
H-1-30-iii
3.701.504
3.812.549
3.886.579
3.960.609
220
H-4-10-i
2.299.479
2.368.463
2.414.453
2.460.442
221
H-4-10-ii
3.832.465
3.947.439
4.024.088
4.100.737
222
H-4-10-iii
6.248.049
6.435.491
6.560.452
6.685.413
223
H-4-11-i
1.532.986
1.578.975
1.609.635
1.640.295
224
H-4-11-ii
1.749.428
1.801.911
1.836.900
1.871.888
225
H-4-11-iii
2.501.519
2.576.564
2.626.595
2.676.625
- 737 No
Kode
INA-CBG
226
H-4-12-i
227
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.959.500
2.018.285
2.057.475
2.096.665
H-4-12-ii
2.654.271
2.733.899
2.786.984
2.840.070
228
H-4-12-iii
4.428.470
4.561.324
4.649.894
4.738.463
229
I-1-01-i
33.072.334
34.064.505
34.725.951
35.387.398
230
I-1-01-ii
33.800.098
34.814.101
35.490.103
36.166.105
231
I-1-01-iii
53.352.807
54.953.391
56.020.447
57.087.503
232
I-1-02-i
18.348.341
18.898.791
19.265.758
19.632.725
233
I-1-02-ii
23.669.359
24.379.440
24.852.827
25.326.215
234
I-1-02-iii
29.173.862
30.049.078
30.632.555
31.216.032
235
I-1-03-i
11.299.561
11.638.548
11.864.539
12.090.530
236
I-1-03-ii
15.487.993
15.952.633
16.262.393
16.572.153
237
I-1-03-iii
22.715.724
23.397.195
23.851.510
24.305.824
238
I-1-04-i
13.785.133
14.198.687
14.474.390
14.750.093
239
I-1-04-ii
17.707.248
18.238.466
18.592.611
18.946.756
240
I-1-04-iii
37.748.177
38.880.622
39.635.586
40.390.550
241
I-1-05-i
24.284.569
25.013.106
25.498.797
25.984.488
242
I-1-05-ii
29.141.482
30.015.727
30.598.556
31.181.386
243
I-1-05-iii
40.098.496
41.301.451
42.103.420
42.905.390
244
I-1-06-i
11.447.207
11.790.623
12.019.567
12.248.511
245
I-1-06-ii
17.276.553
17.794.849
18.140.380
18.485.911
246
I-1-06-iii
22.241.100
22.908.333
23.353.155
23.797.977
15.053.944
15.505.562
15.806.641
16.107.720
18.572.098
19.129.261
19.500.703
19.872.145
20.262.038
20.869.899
21.275.140
21.680.381
2.863.627
2.949.536
3.006.809
3.064.081
3.184.067
3.279.589
3.343.270
3.406.952
4.237.023
4.364.134
4.448.874
4.533.614
8.776.530
9.039.825
9.215.356
9.390.887
12.177.845
12.543.180
12.786.737
13.030.294
247
I-1-07-i
248
I-1-07-ii
249
I-1-07-iii
250
I-1-11-i
251
I-1-11-ii
252
I-1-11-iii
253
I-1-12-i
254
I-1-12-ii

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
KATETERISASI RINGAN
KATETERISASI SEDANG
KATETERISASI BERAT
RINGAN
SEDANG
BERAT

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
- 738 No
Kode
INA-CBG
255
I-1-12-iii
256
I-1-13-i
257
I-1-13-ii
258
I-1-13-iii
259
I-1-14-i
260
I-1-14-ii
261
I-1-14-iii
262
I-1-15-i
263
264
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
16.985.218
17.494.775
17.834.479
18.174.184
5.162.664
5.317.544
5.420.798
5.524.051
6.006.444
6.186.637
6.306.766
6.426.895
10.949.345
11.277.826
11.496.813
11.715.799
18.887.998
19.454.638
19.832.398
20.210.158
23.475.083
24.179.335
24.648.837
25.118.339
30.760.453
31.683.267
32.298.476
32.913.685
3.701.142
3.812.176
3.886.199
3.960.222
I-1-15-ii
10.841.595
11.166.843
11.383.675
11.600.507
I-1-15-iii
56.117.717
57.801.248
58.923.602
60.045.957
8.094.856
8.337.702
8.499.599
8.661.496
21.046.626
21.678.025
22.098.957
22.519.890
24.276.767
25.005.070
25.490.605
25.976.140
2.596.085
2.673.968
2.725.890
2.777.811
5.377.434
5.538.757
5.646.306
5.753.855
31.175.092
32.110.345
32.733.847
33.357.349
3.097.599
3.190.527
3.252.478
3.314.430
5.575.677
5.742.948
5.854.461
5.965.975
7.434.237
7.657.264
7.805.949
7.954.633
9.183.656
9.459.166
9.642.839
9.826.512
19.103.861
19.676.976
20.059.054
20.441.131
29.604.045
30.492.167
31.084.248
31.676.329
12.349.948
12.720.446
12.967.445
13.214.444
17.151.424
17.665.967
18.008.996
18.352.024
21.491.521
22.136.267
22.566.097
22.995.927

KOMPLEKS BERAT
KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

DARAH VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
265
I-1-16-i
266
I-1-16-ii
267
I-1-16-iii
268
I-1-17-i
269
I-1-17-ii
270
I-1-17-iii
271
I-1-20-i
272
I-1-20-ii
273
I-1-20-iii
274
I-1-30-i
275
I-1-30-ii
276
I-1-30-iii
277
I-1-40-i
278
I-1-40-ii
279
I-1-40-iii
280
I-4-10-i
3.591.724
3.699.475
3.771.310
3.843.144
281
I-4-10-ii
5.671.396
5.841.538
5.954.966
6.068.394
282
I-4-10-iii
8.181.483
8.426.928
8.590.558
8.754.187
283
I-4-11-i
4.258.845
4.386.610
4.471.787
4.556.964
- 739 No
Kode
INA-CBG
284
I-4-11-ii
285
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.270.337
5.428.447
5.533.854
5.639.261
I-4-11-iii
9.327.246
9.607.063
9.793.608
9.980.153
286
I-4-12-i
3.730.305
3.842.215
3.916.821
3.991.427
287
I-4-12-ii
5.323.135
5.482.829
5.589.292
5.695.755
288
I-4-12-iii
6.457.712
6.651.443
6.780.598
6.909.752
289
I-4-13-i
3.350.840
3.451.365
3.518.382
3.585.399
290
I-4-13-ii
4.868.086
5.014.129
5.111.491
5.208.852
291
I-4-13-iii
9.964.408
10.263.341
10.462.629
10.661.917
292
I-4-14-i
2.083.913
2.146.430
2.188.108
2.229.787
293
I-4-14-ii
2.438.486
2.511.641
2.560.410
2.609.180
294
I-4-14-iii
3.778.842
3.892.208
3.967.784
4.043.361
295
I-4-15-i
3.065.972
3.157.951
3.219.270
3.280.590
296
I-4-15-ii
4.389.090
4.520.763
4.608.545
4.696.327
297
I-4-15-iii
5.002.507
5.152.582
5.252.633
5.352.683
298
I-4-16-i
2.299.479
2.368.463
2.414.453
2.460.442
299
I-4-16-ii
3.726.663
3.838.463
3.912.996
3.987.530
300
I-4-16-iii
4.694.934
4.835.782
4.929.681
5.023.579
301
I-4-17-i
HIPERTENSI RINGAN
2.057.986
2.119.726
2.160.885
2.202.045
302
I-4-17-ii
HIPERTENSI SEDANG
2.914.313
3.001.742
3.060.029
3.118.315
303
I-4-17-iii
HIPERTENSI BERAT
3.545.401
3.651.763
3.722.671
3.793.579
304
I-4-18-i
3.030.822
3.121.747
3.182.363
3.242.980
305
I-4-18-ii
4.643.017
4.782.307
4.875.168
4.968.028
306
I-4-18-iii
6.259.531
6.447.317
6.572.507
6.697.698
307
I-4-19-i
2.372.016
2.443.176
2.490.616
2.538.057
308
I-4-19-ii
3.885.287
4.001.846
4.079.552
4.157.257
309
I-4-19-iii
4.631.227
4.770.164
4.862.788
4.955.413
310
I-4-20-i
2.878.777
2.965.140
3.022.716
3.080.291
311
I-4-20-ii
3.316.566
3.416.063
3.482.394
3.548.726
312
I-4-20-iii
4.401.635
4.533.684
4.621.717
4.709.750
313
I-4-21-i
3.828.307
3.943.157
4.019.723
4.096.289
314
I-4-21-ii
4.775.565
4.918.832
5.014.343
5.109.855
315
I-4-21-iii
6.514.883
6.710.330
6.840.628
6.970.925
316
I-4-22-i
2.491.102
2.565.835
2.615.657
2.665.479

VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT


RINGAN
SEDANG
KONGENITAL BERAT
RINGAN
SEDANG
BERAT
- 740 No
Kode
INA-CBG
317
I-4-22-ii
318
I-4-22-iii
319
I-4-23-i
320
I-4-23-ii
321
I-4-23-iii
322
I-4-24-i
323
I-4-24-ii
324
I-4-24-iii
325
J-1-01-i
326
J-1-01-ii
327
J-1-01-iii
328
J-1-02-i
329
J-1-02-ii
330
J-1-02-iii
331
J-1-10-i
332
J-1-10-ii
333
J-1-10-iii
334
J-1-20-i
335
J-1-20-ii
336
J-1-20-iii
337
J-1-30-i
338
J-1-30-ii
339
J-1-30-iii
340
J-4-10-i
341
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.870.495
2.956.610
3.014.020
3.071.430
4.187.975
4.313.614
4.397.373
4.481.133
1.887.150
1.943.765
1.981.508
2.019.251
2.316.986
2.386.495
2.432.835
2.479.175
4.527.179
4.662.994
4.753.538
4.844.081
2.250.825
2.318.350
2.363.367
2.408.383
5.619.688
5.788.279
5.900.673
6.013.067
7.105.081
7.318.233
7.460.335
7.602.436
18.485.086
19.039.639
19.409.341
19.779.042
20.134.391
20.738.423
21.141.111
21.543.799
33.098.388
34.091.340
34.753.307
35.415.275
9.269.848
9.547.943
9.733.340
9.918.737
9.930.477
10.228.391
10.427.001
10.625.610
14.674.415
15.114.648
15.408.136
15.701.624
3.617.229
3.725.746
3.798.090
3.870.435
8.736.922
8.999.029
9.173.768
9.348.506
15.469.794
15.933.887
16.243.283
16.552.679
3.126.443
3.220.236
3.282.765
3.345.294
4.547.164
4.683.579
4.774.523
4.865.466
6.837.531
7.042.657
7.179.407
7.316.158
2.108.333
2.171.583
2.213.750
2.255.916
10.325.329
10.635.089
10.841.595
11.048.102
31.140.739
32.074.961
32.697.776
33.320.590
2.433.298
2.506.297
2.554.963
2.603.629
J-4-10-ii
3.479.324
3.583.703
3.653.290
3.722.876
342
J-4-10-iii
5.263.697
5.421.608
5.526.882
5.632.156
343
J-4-11-i
1.535.101
1.581.154
1.611.857
1.642.559
344
J-4-11-ii
2.136.826
2.200.931
2.243.667
2.286.404
345
J-4-11-iii
3.062.126
3.153.990
3.215.233
3.276.475
346
J-4-12-i
EMBOLI PARU RINGAN
2.347.569
2.417.996
2.464.947
2.511.899
347
J-4-12-ii
EMBOLI PARU SEDANG
3.040.021
3.131.222
3.192.022
3.252.823

RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
- 741 No
Kode
INA-CBG
348
J-4-12-iii
349
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
EMBOLI PARU BERAT
4.059.641
4.181.430
4.262.623
4.343.816
J-4-13-i
3.616.147
3.724.632
3.796.955
3.869.278
350
J-4-13-ii
5.315.737
5.475.209
5.581.523
5.687.838
351
J-4-13-iii
8.642.592
8.901.870
9.074.722
9.247.574
352
J-4-14-i
TUMOR PARU RINGAN
2.464.290
2.538.219
2.587.505
2.636.790
353
J-4-14-ii
TUMOR PARU SEDANG
4.128.023
4.251.864
4.334.424
4.416.985
354
J-4-14-iii
TUMOR PARU BERAT
4.908.010
5.055.250
5.153.410
5.251.571
355
J-4-15-i
2.299.479
2.368.463
2.414.453
2.460.442
356
J-4-15-ii
4.161.244
4.286.081
4.369.306
4.452.531
357
J-4-15-iii
5.199.391
5.355.373
5.459.361
5.563.348
358
J-4-16-i
1.916.232
1.973.719
2.012.044
2.050.369
359
J-4-16-ii
2.682.725
2.763.207
2.816.862
2.870.516
360
J-4-16-iii
4.839.354
4.984.535
5.081.322
5.178.109
361
J-4-17-i
2.393.078
2.464.870
2.512.732
2.560.593
362
J-4-17-ii
3.233.459
3.330.463
3.395.132
3.459.802
363
J-4-17-iii
4.227.460
4.354.283
4.438.833
4.523.382
364
J-4-18-i
2.153.093
2.217.686
2.260.748
2.303.809
365
J-4-18-ii
2.997.968
3.087.907
3.147.866
3.207.825
366
J-4-18-iii
3.109.555
3.202.842
3.265.033
3.327.224
367
J-4-19-i
2.682.725
2.763.207
2.816.862
2.870.516
368
J-4-19-ii
3.065.972
3.157.951
3.219.270
3.280.590
369
J-4-19-iii
4.803.204
4.947.300
5.043.365
5.139.429
370
J-4-20-i
2.682.725
2.763.207
2.816.862
2.870.516
371
J-4-20-ii
3.272.429
3.370.602
3.436.051
3.501.499
372
J-4-20-iii
7.394.510
7.616.345
7.764.236
7.912.126
373
J-4-21-i
1.532.986
1.578.975
1.609.635
1.640.295
374
J-4-21-ii
3.782.156
3.895.621
3.971.264
4.046.907
375
J-4-21-iii
5.394.592
5.556.429
5.664.321
5.772.213
376
K-1-10-i
4.130.132
4.254.036
4.336.638
4.419.241
377
K-1-10-ii
5.763.870
5.936.786
6.052.063
6.167.341
378
K-1-10-iii
6.750.484
6.952.999
7.088.008
7.223.018
379
K-1-11-i
3.551.278
3.657.816
3.728.842
3.799.867
380
K-1-11-ii
4.662.399
4.802.271
4.895.519
4.988.767

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT

USUS BESAR (RINGAN)
USUS BESAR (SEDANG)
USUS BESAR (BERAT)
- 742 No
Kode
INA-CBG
381
K-1-11-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
11.832.252
12.187.219
12.423.864
12.660.509
1.910.316
1.967.625
2.005.831
2.044.038
2.489.732
2.564.424
2.614.219
2.664.014
4.952.601
5.101.179
5.200.231
5.299.283
382
K-1-12-i
383
K-1-12-ii
384
K-1-12-iii
385
K-1-13-i
2.169.857
2.234.953
2.278.350
2.321.747
386
K-1-13-ii
3.790.117
3.903.820
3.979.622
4.055.425
387
K-1-13-iii
4.053.393
4.174.995
4.256.063
4.337.130
3.506.617
3.611.816
3.681.948
3.752.080
4.118.919
4.242.487
4.324.865
4.407.243
10.141.973
10.446.232
10.649.071
10.851.911

RINGAN
SEDANG
BERAT
388
K-1-14-i
389
K-1-14-ii
390
K-1-14-iii
391
K-1-20-i
6.803.866
7.007.982
7.144.059
7.280.136
392
K-1-20-ii
9.496.402
9.781.294
9.971.222
10.161.150
393
K-1-20-iii
20.284.764
20.893.307
21.299.002
21.704.697
394
K-1-30-i
4.478.643
4.613.002
4.702.575
4.792.148
395
K-1-30-ii
8.260.263
8.508.071
8.673.276
8.838.482
396
K-1-30-iii
12.864.300
13.250.229
13.507.515
13.764.801
397
K-1-40-i
4.499.338
4.634.318
4.724.304
4.814.291
398
K-1-40-ii
4.951.074
5.099.606
5.198.628
5.297.649
399
K-1-40-iii
8.210.880
8.457.206
8.621.424
8.785.641
400
K-1-50-i
3.431.909
3.534.866
3.603.504
3.672.143
401
K-1-50-ii
4.444.484
4.577.819
4.666.708
4.755.598
402
K-1-50-iii
PROSEDUR ANAL BERAT
6.309.985
6.499.285
6.625.485
6.751.684
403
K-4-10-i
2.599.424
2.677.407
2.729.395
2.781.384
404
K-4-10-ii
3.110.364
3.203.675
3.265.882
3.328.089
405
K-4-10-iii
12.879.976
13.266.375
13.523.975
13.781.574
406
K-4-11-i
1.532.986
1.578.975
1.609.635
1.640.295
407
K-4-11-ii
2.299.479
2.368.463
2.414.453
2.460.442
408
K-4-11-iii
4.178.982
4.304.351
4.387.931
4.471.510
409
K-4-12-i
1.532.986
1.578.975
1.609.635
1.640.295
410
K-4-12-ii
2.290.257
2.358.965
2.404.770
2.450.575
411
K-4-12-iii
5.496.454
5.661.348
5.771.277
5.881.206
412
K-4-13-i

(RINGAN)
2.299.479
2.368.463
2.414.453
2.460.442

(RINGAN)
(SEDANG)
(BERAT)
- 743 No
Kode
INA-CBG
413
K-4-13-ii
414
K-4-13-iii
415
K-4-14-i
416
K-4-14-ii
417
K-4-14-iii
418
K-4-15-i
419
K-4-15-ii
420
K-4-15-iii
421
K-4-16-i
422
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.978.391
3.067.743
3.127.311
3.186.879
4.871.345
5.017.485
5.114.912
5.212.339
1.916.232
1.973.719
2.012.044
2.050.369
2.593.421
2.671.223
2.723.092
2.774.960
3.922.796
4.040.480
4.118.936
4.197.392
1.916.232
1.973.719
2.012.044
2.050.369
3.603.040
3.711.131
3.783.192
3.855.252
5.126.477
5.280.271
5.382.801
5.485.330
1.916.232
1.973.719
2.012.044
2.050.369
K-4-16-ii
2.299.479
2.368.463
2.414.453
2.460.442
423
K-4-16-iii
2.806.813
2.891.017
2.947.153
3.003.290
424
K-4-17-i
1.532.986
1.578.975
1.609.635
1.640.295
425
K-4-17-ii
2.236.655
2.303.755
2.348.488
2.393.221
426
K-4-17-iii
2.976.760
3.066.062
3.125.598
3.185.133
427
K-4-18-i
1.532.986
1.578.975
1.609.635
1.640.295
428
K-4-18-ii
2.379.830
2.451.225
2.498.822
2.546.418
429
K-4-18-iii
2.815.327
2.899.787
2.956.093
3.012.400
430
L-1-20-i
15.687.430
16.158.053
16.471.802
16.785.550
431
L-1-20-ii
16.319.252
16.808.829
17.135.214
17.461.600
432
L-1-20-iii
25.002.978
25.753.067
26.253.127
26.753.186
433
L-1-30-i
7.115.357
7.328.817
7.471.124
7.613.431
434
L-1-30-ii
10.306.617
10.615.815
10.821.948
11.028.080
435
L-1-30-iii
10.870.265
11.196.373
11.413.778
11.631.183
436
L-1-40-i
2.872.974
2.959.163
3.016.623
3.074.082
437
L-1-40-ii
6.466.202
6.660.188
6.789.512
6.918.836
438
L-1-40-iii
10.958.504
11.287.259
11.506.429
11.725.599
439
L-1-50-i
5.162.664
5.317.544
5.420.798
5.524.051
440
L-1-50-ii
9.292.796
9.571.580
9.757.436
9.943.292
441
L-1-50-iii
11.236.305
11.573.394
11.798.120
12.022.847
442
L-4-10-i
2.299.479
2.368.463
2.414.453
2.460.442
443
L-4-10-ii
2.682.725
2.763.207
2.816.862
2.870.516

(SEDANG)
RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
- 744 No
Kode
INA-CBG
444
L-4-10-iii
445
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.426.924
5.589.732
5.698.270
5.806.809
L-4-11-i
2.174.888
2.240.135
2.283.633
2.327.130
446
L-4-11-ii
2.979.559
3.068.946
3.128.537
3.188.128
447
L-4-11-iii
8.080.191
8.322.597
8.484.200
8.645.804
448
L-4-12-i
2.299.479
2.368.463
2.414.453
2.460.442
449
L-4-12-ii
3.373.869
3.475.085
3.542.562
3.610.040
450
L-4-12-iii
5.657.579
5.827.306
5.940.458
6.053.610
451
L-4-13-i
1.443.313
1.486.613
1.515.479
1.544.345
452
L-4-13-ii
1.664.226
1.714.152
1.747.437
1.780.721
453
L-4-13-iii
2.496.468
2.571.362
2.621.292
2.671.221
454
L-4-14-i
1.532.986
1.578.975
1.609.635
1.640.295
455
L-4-14-ii
2.299.479
2.368.463
2.414.453
2.460.442
456
L-4-14-iii
3.595.277
3.703.135
3.775.040
3.846.946
457
M-1-01-i
7.473.904
7.698.121
7.847.599
7.997.077
458
M-1-01-ii
8.342.085
8.592.348
8.759.190
8.926.031
459
M-1-01-iii
11.718.370
12.069.921
12.304.288
12.538.656
460
M-1-02-i
5.293.430
5.452.233
5.558.101
5.663.970
461
M-1-02-ii
8.690.806
8.951.530
9.125.346
9.299.162
462
M-1-02-iii
15.738.650
16.210.810
16.525.583
16.840.356
463
M-1-03-i
13.422.928
13.825.615
14.094.074
14.362.533
464
M-1-03-ii
15.708.751
16.180.013
16.494.188
16.808.363
465
M-1-03-iii
16.004.260
16.484.388
16.804.473
17.124.558
466
M-1-04-i
3.491.917
3.596.675
3.666.513
3.736.351
467
M-1-04-ii
4.476.601
4.610.899
4.700.432
4.789.964
468
M-1-04-iii
5.601.623
5.769.672
5.881.704
5.993.736
469
M-1-05-i
5.439.736
5.602.928
5.711.723
5.820.518
470
M-1-05-ii
6.286.877
6.475.484
6.601.221
6.726.959
471
M-1-05-iii
10.708.264
11.029.512
11.243.678
11.457.843
472
M-1-07-i
6.004.707
6.184.849
6.304.943
6.425.037
473
M-1-07-ii
8.044.431
8.285.764
8.446.653
8.607.542
474
M-1-07-iii
16.387.270
16.878.888
17.206.633
17.534.378
475
M-1-10-i
3.752.827
3.865.411
3.940.468
4.015.525


TULANG WAJAH RINGAN
- 745 No
Kode
INA-CBG
476
M-1-10-ii
477
M-1-10-iii
478
M-1-20-i
479
M-1-20-ii
480
M-1-20-iii
481
M-1-30-i
482
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
13.940.051
14.358.252
14.637.053
14.915.854
17.051.339
17.562.879
17.903.906
18.244.933
3.712.515
3.823.891
3.898.141
3.972.391
5.299.282
5.458.261
5.564.246
5.670.232
10.300.649
10.609.669
10.815.682
11.021.695
2.220.639
2.287.258
2.331.671
2.376.084
M-1-30-ii
4.588.405
4.726.057
4.817.825
4.909.594
483
M-1-30-iii
PROSEDUR KAKI BERAT
6.844.933
7.050.281
7.187.180
7.324.078
484
M-1-40-i
2.243.783
2.311.097
2.355.972
2.400.848
485
M-1-40-ii
4.130.132
4.254.036
4.336.638
4.419.241
486
M-1-40-iii
7.227.730
7.444.562
7.589.117
7.733.671
487
M-1-50-i
2.971.608
3.060.756
3.120.189
3.179.621
488
M-1-50-ii
5.981.917
6.161.375
6.281.013
6.400.651
489
M-1-50-iii
8.260.263
8.508.071
8.673.276
8.838.482
490
M-1-60-i
2.242.626
2.309.905
2.354.758
2.399.610
491
M-1-60-ii
4.489.753
4.624.445
4.714.240
4.804.036
492
M-1-60-iii
7.813.758
8.048.171
8.204.446
8.360.721
493
M-1-70-i
3.004.218
3.094.344
3.154.429
3.214.513
494
M-1-70-ii
6.130.092
6.313.995
6.436.597
6.559.199
495
M-1-70-iii
9.882.449
10.178.922
10.376.571
10.574.220
496
M-1-80-i
2.420.586
2.493.204
2.541.616
2.590.028
497
M-1-80-ii
3.659.432
3.769.215
3.842.403
3.915.592
498
M-1-80-iii
8.424.960
8.677.709
8.846.208
9.014.707
499
M-4-10-i
1.532.986
1.578.975
1.609.635
1.640.295
500
M-4-10-ii
2.338.952
2.409.120
2.455.899
2.502.678
501
M-4-10-iii
FRAKTUR FEMUR BERAT
4.966.640
5.115.639
5.214.972
5.314.305
502
M-4-11-i
2.028.829
2.089.694
2.130.270
2.170.847
503
M-4-11-ii
4.654.436
4.794.069
4.887.157
4.980.246
504
M-4-11-iii
8.261.514
8.509.360
8.674.590
8.839.820
505
M-4-12-i
1.532.986
1.578.975
1.609.635
1.640.295
506
M-4-12-ii
2.789.266
2.872.944
2.928.729
2.984.515

TULANG WAJAH SEDANG
TULANG WAJAH BERAT

RINGAN
SEDANG
BERAT

SELAIN KAKI (BERAT)

PANGGUL RINGAN
PANGGUL SEDANG
PANGGUL BERAT
PELVIS RINGAN
PELVIS SEDANG
- 746 No
Kode
INA-CBG
507
M-4-12-iii
508
M-4-13-i
509
M-4-13-ii
510
M-4-13-iii
511
M-4-14-i
512
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.586.170
5.753.755
5.865.479
5.977.202
2.830.027
2.914.928
2.971.529
3.028.129
3.832.465
3.947.439
4.024.088
4.100.737
8.418.622
8.671.181
8.839.554
9.007.926
3.065.972
3.157.951
3.219.270
3.280.590
M-4-14-ii
3.980.453
4.099.867
4.179.476
4.259.085
513
M-4-14-iii
OSTEOMIELITIS BERAT
5.962.290
6.141.159
6.260.405
6.379.651
514
M-4-15-i
1.912.838
1.970.224
2.008.480
2.046.737
515
M-4-15-ii
2.550.612
2.627.131
2.678.143
2.729.155
516
M-4-15-iii
6.515.190
6.710.646
6.840.950
6.971.253
517
M-4-16-i
1.916.232
1.973.719
2.012.044
2.050.369
518
M-4-16-ii
3.065.972
3.157.951
3.219.270
3.280.590
519
M-4-16-iii
5.700.955
5.871.984
5.986.003
6.100.022
520
M-4-17-i
1.916.232
1.973.719
2.012.044
2.050.369
521
M-4-17-ii
2.682.725
2.763.207
2.816.862
2.870.516
522
M-4-17-iii
3.746.568
3.858.965
3.933.897
4.008.828
523
M-4-18-i
2.246.122
2.313.506
2.358.428
2.403.350
524
M-4-18-ii
3.065.972
3.157.951
3.219.270
3.280.590
525
M-4-18-iii
3.809.292
3.923.570
3.999.756
4.075.942
526
M-4-19-i
1.670.022
1.720.123
1.753.523
1.786.924
527
M-4-19-ii
2.812.852
2.897.238
2.953.495
3.009.752
528
M-4-19-iii
5.493.708
5.658.519
5.768.394
5.878.268
529
M-4-20-i
1.532.986
1.578.975
1.609.635
1.640.295
530
M-4-20-ii
2.299.479
2.368.463
2.414.453
2.460.442
531
M-4-20-iii
2.548.365
2.624.815
2.675.783
2.726.750
532
M-4-21-i
1.532.986
1.578.975
1.609.635
1.640.295
533
M-4-21-ii
2.000.932
2.060.960
2.100.979
2.140.997
534
M-4-21-iii
4.877.428
5.023.751
5.121.299
5.218.848
535
N-1-01-i
4.147.845
4.272.281
4.355.237
4.438.194
536
N-1-01-ii
5.609.867
5.778.163
5.890.360
6.002.558
537
N-1-01-iii
11.894.587
12.251.424
12.489.316
12.727.208

PELVIS BERAT

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
RINGAN
SEDANG
BERAT
ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
- 747 No
Kode
INA-CBG
538
N-1-11-i
539
N-1-11-ii
540
N-1-11-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.722.273
5.893.941
6.008.386
6.122.832
7.739.245
7.971.422
8.126.207
8.280.992
16.409.501
16.901.786
17.229.976
17.558.166
3.097.599
3.190.527
3.252.479
3.314.431
7.206.344
7.422.534
7.566.661
7.710.788
13.134.011
13.528.031
13.790.712
14.053.392
541
N-1-12-i
542
N-1-12-ii
543
N-1-12-iii
544
N-1-20-i
4.193.904
4.319.721
4.403.599
4.487.477
545
N-1-20-ii
8.315.021
8.564.471
8.730.772
8.897.072
546
N-1-20-iii
9.511.630
9.796.979
9.987.211
10.177.444
547
N-1-30-i
4.989.389
5.139.071
5.238.858
5.338.646
548
N-1-30-ii
7.581.999
7.809.459
7.961.099
8.112.739
549
N-1-30-iii
8.728.131
8.989.975
9.164.538
9.339.100
550
N-1-40-i
4.495.928
4.630.806
4.720.724
4.810.643
551
N-1-40-ii
6.094.391
6.277.222
6.399.110
6.520.998
552
N-1-40-iii
7.087.952
7.300.591
7.442.350
7.584.109
553
N-4-10-i
1.916.232
1.973.719
2.012.044
2.050.369
554
N-4-10-ii
2.565.889
2.642.865
2.694.183
2.745.501
555
N-4-10-iii
5.616.269
5.784.757
5.897.082
6.009.407
556
N-4-11-i
1.467.457
1.511.480
1.540.830
1.570.179
557
N-4-11-ii
2.479.967
2.554.366
2.603.965
2.653.564
558
N-4-11-iii
2.874.349
2.960.579
3.018.066
3.075.553
559
N-4-12-i
1.532.986
1.578.975
1.609.635
1.640.295
560
N-4-12-ii
2.299.479
2.368.463
2.414.453
2.460.442
561
N-4-12-iii
3.817.891
3.932.427
4.008.785
4.085.143
562
N-4-13-i
BATU URIN RINGAN
2.022.480
2.083.154
2.123.604
2.164.053
563
N-4-13-ii
BATU URIN SEDANG
2.438.350
2.511.500
2.560.267
2.609.034
564
N-4-13-iii
BATU URIN BERAT
6.004.987
6.185.137
6.305.236
6.425.336
1.327.850
1.367.685
1.394.242
1.420.799
2.044.722
2.106.064
2.146.958
2.187.852
3.315.887
3.415.364
3.481.681
3.547.999
565
N-4-14-i
566
N-4-14-ii
567
N-4-14-iii

URIN BAWAH RINGAN
URIN BAWAH SEDANG
URIN BAWAH BERAT
RINGAN
SEDANG
BERAT
GINJAL RINGAN
GINJAL SEDANG
GINJAL BERAT

(RINGAN)
(SEDANG)
(BERAT)
- 748 No
Kode
INA-CBG
568
N-4-15-i
569
N-4-15-ii
570
N-4-15-iii
571
N-4-16-i
572
N-4-16-ii
573
N-4-16-iii
574
O-6-10-i
575
O-6-10-ii
576
O-6-10-iii
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
584
585
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.969.969
2.029.068
2.068.467
2.107.867
2.703.410
2.784.513
2.838.581
2.892.649
3.085.079
3.177.631
3.239.333
3.301.035
2.556.747
2.633.450
2.684.585
2.735.720
3.065.972
3.157.951
3.219.270
3.280.590
6.447.283
6.640.701
6.769.647
6.898.592
3.775.164
3.888.419
3.963.922
4.039.425
4.191.007
4.316.737
4.400.558
4.484.378
4.698.169
4.839.114
4.933.078
5.027.041
1.973.036
2.032.227
2.071.687
2.111.148
2.531.225
2.607.161
2.657.786
2.708.410
4.289.640
4.418.329
4.504.122
4.589.915
1.718.129
1.769.672
1.804.035
1.838.398
2.063.468
2.125.372
2.166.642
2.207.911
2.592.452
2.670.226
2.722.075
2.773.924
1.721.875
1.773.531
1.807.968
1.842.406
O-6-13-ii
2.537.705
2.613.836
2.664.590
2.715.345
O-6-13-iii
2.999.176
3.089.151
3.149.135
3.209.118
38.517.557
39.673.083
40.443.434
41.213.786
47.659.451
49.089.235
50.042.424
50.995.613
55.938.835
57.617.001
58.735.777
59.854.554
46.667.026
48.067.037
49.000.377
49.933.718
53.531.882
55.137.839
56.208.476
57.279.114
61.164.003
62.998.923
64.222.203
65.445.483
2.581.332
2.658.772
2.710.399
2.762.025
3.613.865
3.722.281
3.794.558
3.866.836
5.692.657
5.863.437
5.977.290
6.091.143
23.053.110
23.744.703
24.205.765
24.666.828
29.917.966
30.815.505
31.413.865
32.012.224
586
P-8-01-i
587
P-8-01-ii
588
P-8-01-iii
589
P-8-02-i
590
P-8-02-ii
591
P-8-02-iii
592
P-8-03-i
593
P-8-03-ii
594
P-8-03-iii
595
P-8-04-i
596
P-8-04-ii

SALURAN URIN RINGAN
SALURAN URIN SEDANG
SALURAN URIN BERAT
RINGAN
SEDANG
BERAT
&KURET RINGAN
KURET SEDANG
KURET BERAT

- 749 No
Kode
INA-CBG
597
P-8-04-iii
598
P-8-05-i
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii
603
P-8-06-iii
604
P-8-07-i
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
614
P-8-11-ii
615
P-8-11-iii
616
P-8-12-i
617
P-8-12-ii
618
P-8-12-iii
619
P-8-13-i
620
P-8-13-ii
621
P-8-13-iii
622
P-8-14-i
623
P-8-14-ii
624
P-8-14-iii
Deskripsi (INA-CBG)
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
RINGAN
SEDANG
BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
42.894.833
44.181.678
45.039.575
45.897.471
12.535.534
12.911.600
13.162.310
13.413.021
17.767.429
18.300.452
18.655.801
19.011.149
26.177.922
26.963.259
27.486.818
28.010.376
2.065.066
2.127.018
2.168.319
2.209.620
5.196.247
5.352.134
5.456.059
5.559.984
9.665.611
9.955.580
10.148.892
10.342.204
3.613.865
3.722.281
3.794.558
3.866.836
10.132.408
10.436.380
10.639.028
10.841.676
13.422.928
13.825.615
14.094.074
14.362.533
2.618.902
2.697.469
2.749.847
2.802.225
3.717.900
3.829.437
3.903.795
3.978.153
5.248.533
5.405.989
5.510.960
5.615.931
1.624.764
1.673.507
1.706.002
1.738.497
2.353.707
2.424.318
2.471.392
2.518.467
4.621.021
4.759.651
4.852.072
4.944.492
4.576.026
4.713.307
4.804.827
4.896.348
9.742.233
10.034.500
10.229.345
10.424.190
9.946.335
10.244.725
10.443.652
10.642.578
2.158.849
2.223.614
2.266.791
2.309.968
3.356.635
3.457.334
3.524.467
3.591.600
3.960.120
4.078.923
4.158.126
4.237.328
1.115.809
1.149.284
1.171.600
1.193.916
2.064.797
2.126.741
2.168.037
2.209.332
3.088.124
3.180.768
3.242.530
3.304.293
2.038.700
2.099.861
2.140.635
2.181.409
4.162.448
4.287.322
4.370.571
4.453.820
4.566.190
4.703.176
4.794.500
4.885.824
- 750 No
Kode
INA-CBG
625
P-8-15-i
626
P-8-15-ii
627
P-8-15-iii
628
P-8-16-i
629
P-8-16-ii
630
P-8-16-iii
631
P-8-17-i
632
P-8-17-ii
633
P-8-17-iii
634
S-4-10-i
635
S-4-10-ii
636
S-4-10-iii
637
S-4-11-i
638
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.533.166
1.579.161
1.609.824
1.640.488
3.064.396
3.156.327
3.217.615
3.278.903
3.599.607
3.707.595
3.779.587
3.851.580
1.387.878
1.429.514
1.457.271
1.485.029
1.968.764
2.027.826
2.067.202
2.106.577
2.555.552
2.632.218
2.683.329
2.734.441
915.996
943.476
961.796
980.116
3.042.629
3.133.908
3.194.761
3.255.613
6.141.353
6.325.594
6.448.421
6.571.248
1.532.986
1.578.975
1.609.635
1.640.295
1.916.232
1.973.719
2.012.044
2.050.369
2.490.773
2.565.496
2.615.312
2.665.127
958.116
986.860
1.006.022
1.025.184
S-4-11-ii
1.458.271
1.502.019
1.531.184
1.560.350
639
S-4-11-iii
2.359.227
2.430.004
2.477.189
2.524.373
640
S-4-12-i
1.149.739
1.184.232
1.207.226
1.230.221
641
S-4-12-ii
1.532.986
1.578.975
1.609.635
1.640.295
642
S-4-12-iii
2.994.043
3.083.864
3.143.745
3.203.626
643
S-4-13-i
1.532.986
1.578.975
1.609.635
1.640.295
644
S-4-13-ii
2.709.975
2.791.275
2.845.474
2.899.674
645
S-4-13-iii
5.517.854
5.683.390
5.793.747
5.904.104
646
S-4-14-i
934.020
962.041
980.721
999.402
647
S-4-14-ii
1.984.172
2.043.697
2.083.381
2.123.064
648
S-4-14-iii
3.762.697
3.875.578
3.950.832
4.026.086
649
S-4-15-i
706.408
727.600
741.728
755.857
650
S-4-15-ii
1.333.233
1.373.230
1.399.894
1.426.559
651
S-4-15-iii
1.726.846
1.778.651
1.813.188
1.847.725
652
S-4-16-i
LUKA BAKAR RINGAN
2.682.725
2.763.207
2.816.862
2.870.516
653
S-4-16-ii
LUKA BAKAR SEDANG
3.788.882
3.902.549
3.978.326
4.054.104
654
S-4-16-iii
LUKA BAKAR BERAT
6.765.637
6.968.606
7.103.919
7.239.232
1.430.482
1.473.396
1.502.006
1.530.615
1.916.232
1.973.719
2.012.044
2.050.369
655
S-4-17-i
656
S-4-17-ii

ASPIRASI RINGAN
ASPIRASI SEDANG
ASPIRASI BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT

PASIEN RINGAN
PASIEN SEDANG
PASIEN BERAT

- 751 No
Kode
INA-CBG
657
S-4-17-iii
658
T-1-10-i
659
T-1-10-ii
660
T-1-10-iii
661
T-4-10-i
662
T-4-10-ii
663
T-4-10-iii
664
T-4-11-i
665
T-4-11-ii
666
T-4-11-iii
667
T-4-12-i
668
T-4-12-ii
669
T-4-12-iii
670
U-1-10-i
671
672
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.124.795
3.218.539
3.281.035
3.343.531
1.476.652
1.520.952
1.550.485
1.580.018
1.983.043
2.042.535
2.082.196
2.121.856
3.607.802
3.716.036
3.788.193
3.860.349
645.930
665.308
678.226
691.145
1.230.999
1.267.929
1.292.549
1.317.169
1.789.538
1.843.224
1.879.015
1.914.806
638.787
657.951
670.727
683.503
1.005.270
1.035.428
1.055.533
1.075.639
1.619.193
1.667.769
1.700.153
1.732.537
1.341.363
1.381.604
1.408.431
1.435.258
2.027.396
2.088.218
2.128.766
2.169.314
3.153.899
3.248.516
3.311.594
3.374.672
1.427.758
1.470.590
1.499.146
1.527.701
U-1-10-ii
2.913.427
3.000.830
3.059.099
3.117.367
U-1-10-iii
12.580.768
12.958.191
13.209.806
13.461.421
6.195.197
6.381.053
6.504.957
6.628.861
8.260.263
8.508.071
8.673.276
8.838.482
13.877.977
14.294.317
14.571.876
14.849.436

DOKTER RINGAN
DOKTER SEDANG
DOKTER BERAT

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
673
U-1-11-i
674
U-1-11-ii
675
U-1-11-iii
676
U-1-12-i
3.785.952
3.899.531
3.975.250
4.050.969
677
U-1-12-ii
9.292.796
9.571.580
9.757.436
9.943.292
678
U-1-12-iii
12.066.872
12.428.878
12.670.215
12.911.553
679
U-1-13-i
4.130.132
4.254.036
4.336.638
4.419.241
680
U-1-13-ii
4.659.909
4.799.706
4.892.904
4.986.103
681
U-1-13-iii
8.985.619
9.255.187
9.434.900
9.614.612
2.278.877
2.347.243
2.392.821
2.438.398
2.796.640
2.880.539
2.936.472
2.992.405
3.314.097
3.413.520
3.479.802
3.546.084

682
U-1-14-i
683
U-1-14-ii
684
U-1-14-iii
685
U-1-15-i
1.338.471
1.378.625
1.405.395
1.432.164
686
U-1-15-ii
1.901.874
1.958.930
1.996.968
2.035.005
687
U-1-15-iii
3.747.719
3.860.151
3.935.105
4.010.060
- 752 No
Kode
INA-CBG
688
U-1-20-i
689
U-1-20-ii
690
U-1-20-iii
691
U-1-30-i
692
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.462.042
3.565.903
3.635.144
3.704.385
6.162.435
6.347.308
6.470.557
6.593.805
15.202.952
15.659.040
15.963.099
16.267.158
2.969.828
3.058.923
3.118.320
3.177.716
U-1-30-ii
4.009.268
4.129.546
4.209.732
4.289.917
693
U-1-30-iii
7.859.319
8.095.098
8.252.284
8.409.471
694
U-4-10-i
2.764.414
2.847.347
2.902.635
2.957.923
695
U-4-10-ii
6.929.806
7.137.700
7.276.296
7.414.892
696
U-4-10-iii
10.109.077
10.412.350
10.614.531
10.816.713
697
U-4-11-i
1.532.986
1.578.975
1.609.635
1.640.295
698
U-4-11-ii
2.299.479
2.368.463
2.414.453
2.460.442
699
U-4-11-iii
3.180.170
3.275.575
3.339.179
3.402.782
700
U-4-12-i
1.532.986
1.578.975
1.609.635
1.640.295
701
U-4-12-ii
1.787.108
1.840.722
1.876.464
1.912.206
702
U-4-12-iii
2.841.421
2.926.664
2.983.492
3.040.321
703
U-4-13-i
1.506.046
1.551.227
1.581.348
1.611.469
704
U-4-13-ii
1.750.866
1.803.392
1.838.409
1.873.427
705
U-4-13-iii
1.987.980
2.047.620
2.087.379
2.127.139
706
U-4-14-i
1.916.232
1.973.719
2.012.044
2.050.369
707
U-4-14-ii
2.299.479
2.368.463
2.414.453
2.460.442
708
U-4-14-iii
3.852.026
3.967.587
4.044.627
4.121.668
709
U-4-15-i
1.532.986
1.578.975
1.609.635
1.640.295
710
U-4-15-ii
1.916.232
1.973.719
2.012.044
2.050.369
711
U-4-15-iii
2.683.245
2.763.743
2.817.408
2.871.073
712
V-1-10-i
4.481.426
4.615.869
4.705.497
4.795.126
713
V-1-10-ii
5.162.664
5.317.544
5.420.798
5.524.051
714
V-1-10-iii
9.809.062
10.103.334
10.299.516
10.495.697
715
V-1-11-i
5.162.664
5.317.544
5.420.798
5.524.051
716
V-1-11-ii
5.761.620
5.934.469
6.049.701
6.164.934
717
V-1-11-iii
8.532.077
8.788.040
8.958.681
9.129.323
2.788.254
2.871.902
2.927.667
2.983.432
10.655.780
10.975.453
11.188.569
11.401.685
12.441.594
12.814.842
13.063.674
13.312.506
718
V-1-12-i
719
V-1-12-ii
720
V-1-12-iii


DAN TELINGA RINGAN
DAN TELINGA SEDANG
DAN TELINGA BERAT


KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

- 753 No
Kode
INA-CBG
721
V-1-13-i
722
V-1-13-ii
723
V-1-13-iii
724
V-1-14-i
725
V-1-14-ii
726
V-1-14-iii
727
V-1-15-i
728
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.226.089
4.352.872
4.437.394
4.521.916
8.030.782
8.271.706
8.432.321
8.592.937
12.390.395
12.762.107
13.009.914
13.257.722
5.094.600
5.247.438
5.349.330
5.451.222
7.409.659
7.631.949
7.780.142
7.928.335
10.072.353
10.374.524
10.575.971
10.777.418
2.401.820
2.473.875
2.521.911
2.569.948
V-1-15-ii
4.575.000
4.712.250
4.803.750
4.895.250
729
V-1-15-iii
8.042.762
8.284.045
8.444.900
8.605.756
730
V-4-10-i
3.867.537
3.983.563
4.060.914
4.138.264
731
V-4-10-ii
4.995.386
5.145.247
5.245.155
5.345.063
732
V-4-10-iii
9.547.059
9.833.470
10.024.412
10.215.353
733
V-4-11-i
1.966.787
2.025.791
2.065.127
2.104.462
734
V-4-11-ii
2.873.790
2.960.004
3.017.480
3.074.956
735
V-4-11-iii
4.741.564
4.883.811
4.978.642
5.073.473
736
W-1-01-i
5.783.318
5.956.817
6.072.484
6.188.150
737
W-1-01-ii
6.965.732
7.174.704
7.314.018
7.453.333
738
W-1-01-iii
15.385.918
15.847.495
16.155.214
16.462.932
739
W-1-10-i
1.610.647
1.658.966
1.691.179
1.723.392
740
W-1-10-ii
3.005.732
3.095.904
3.156.018
3.216.133
741
W-1-10-iii
4.916.423
5.063.916
5.162.244
5.260.573
742
W-1-11-i
1.672.927
1.723.114
1.756.573
1.790.031
743
W-1-11-ii
3.226.451
3.323.244
3.387.773
3.452.302
744
W-1-11-iii
6.195.197
6.381.053
6.504.957
6.628.861
745
W-1-12-i
1.520.105
1.565.708
1.596.111
1.626.513
746
W-1-12-ii
1.728.331
1.780.180
1.814.747
1.849.314
747
W-1-12-iii
2.654.934
2.734.582
2.787.680
2.840.779
748
W-1-13-i
1.809.285
1.863.563
1.899.749
1.935.934
749
W-1-13-ii
1.964.362
2.023.292
2.062.580
2.101.867
750
W-1-13-iii
2.638.500
2.717.655
2.770.425
2.823.195
751
W-1-20-i
4.929.785
5.077.678
5.176.274
5.274.870
752
W-1-20-ii
6.934.482
7.142.517
7.281.206
7.419.896

NON KOMPLEK (BERAT)

RINGAN
SEDANG
BERAT

SERVIK RINGAN
SERVIK SEDANG
SERVIK BERAT
ENDOSKOP RINGAN
ENDOSKOP SEDANG
ENDOSKOP BERAT
- 754 No
Kode
INA-CBG
753
W-1-20-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
8.760.206
9.023.012
9.198.216
9.373.420
2.691.168
2.771.903
2.825.727
2.879.550
4.292.553
4.421.329
4.507.180
4.593.031
11.414.953
11.757.402
11.985.701
12.214.000
754
W-1-30-i
755
W-1-30-ii
756
W-1-30-iii
757
W-4-10-i
2.006.937
2.067.145
2.107.284
2.147.423
758
W-4-10-ii
2.712.601
2.793.979
2.848.231
2.902.483
759
W-4-10-iii
6.131.944
6.315.902
6.438.541
6.561.180
760
W-4-11-i
1.916.232
1.973.719
2.012.044
2.050.369
761
W-4-11-ii
3.065.972
3.157.951
3.219.270
3.280.590
762
W-4-11-iii
3.726.064
3.837.846
3.912.368
3.986.889
1.532.986
1.578.975
1.609.635
1.640.295
2.107.856
2.171.091
2.213.248
2.255.406
2.350.025
2.420.526
2.467.526
2.514.527

763
W-4-12-i
764
W-4-12-ii
765
W-4-12-iii
766
W-4-13-i
ABORTUS RINGAN
840.708
865.929
882.743
899.557
767
W-4-13-ii
ABORTUS SEDANG
1.149.739
1.184.232
1.207.226
1.230.221
768
W-4-13-iii
ABORTUS BERAT
1.532.986
1.578.975
1.609.635
1.640.295
769
W-4-14-i
1.149.739
1.184.232
1.207.226
1.230.221
770
W-4-14-ii
1.478.751
1.523.113
1.552.688
1.582.263
771
W-4-14-iii
1.860.721
1.916.542
1.953.757
1.990.971
772
W-4-15-i
958.749
987.511
1.006.686
1.025.861
773
W-4-15-ii
1.066.311
1.098.301
1.119.627
1.140.953
774
W-4-15-iii
1.476.409
1.520.702
1.550.230
1.579.758
775
W-4-16-i
1.149.739
1.184.232
1.207.226
1.230.221
776
W-4-16-ii
1.532.986
1.578.975
1.609.635
1.640.295
777
W-4-16-iii
2.090.018
2.152.718
2.194.519
2.236.319
778
W-4-17-i
939.056
967.228
986.009
1.004.790
779
W-4-17-ii
1.532.986
1.578.975
1.609.635
1.640.295
780
W-4-17-iii
2.900.104
2.987.108
3.045.110
3.103.112
781
Z-4-10-i
REHABILITASI RINGAN
2.630.422
2.709.335
2.761.943
2.814.552
782
Z-4-10-ii
REHABILITASI SEDANG
3.491.506
3.596.251
3.666.081
3.735.911
783
Z-4-10-iii
REHABILITASI BERAT
4.960.017
5.108.818
5.208.018
5.307.218
784
Z-4-11-i
2.296.069
2.364.951
2.410.873
2.456.794
785
Z-4-11-ii
2.763.960
2.846.879
2.902.158
2.957.437
786
Z-4-11-iii
4.373.076
4.504.268
4.591.730
4.679.191
- 755 No
Kode
INA-CBG
787
Z-4-12-i
788
Z-4-12-ii
789
Z-4-12-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.149.739
1.184.232
1.207.226
1.230.221
2.342.556
2.412.833
2.459.684
2.506.535
2.977.018
3.066.329
3.125.869
3.185.409
- 756 b. RawatJalan
No
Kode
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
775.006
798.256
813.756
829.256
1.005.304
1.035.463
1.055.569
1.075.675
1.869.494
1.925.579
1.962.969
2.000.359
1.544.956
1.591.304
1.622.204
1.653.103
1.290.677
1.329.398
1.355.211
1.381.025
452.517
466.093
475.143
484.193
1.009.054
1.039.326
1.059.507
1.079.688

207.327
213.547
217.694
221.840
C-3-10-0
565.560
582.527
593.838
605.149
10
C-3-11-0

KANDUNG KEMIH
894.454
921.288
939.177
957.066
11
C-3-12-0
202.771
208.854
212.909
216.965
196.904
202.812
206.750
210.688
1.676.251
1.726.538
1.760.063
1.793.588
1.536.351
1.582.441
1.613.168
1.643.895

LAPAROSKOPI
PANKREAS
LAPAROSKOPI
EMPEDU

OVARIUM
GASTROINTESTINAL
GINJAL ATAU PROSTAT
12
C-3-13-0
13
C-3-14-0
14
C-3-15-0
15
C-3-16-0
348.407
358.860
365.828
372.796
16
C-3-17-0

LEHER
231.123
238.057
242.679
247.302
17
C-3-18-0
102.470
105.544
107.594
109.643
18
C-3-19-0

MYELOMA ATAU TESTIS
144.913
149.261
152.159
155.057
19
C-3-20-0
2.885.957
2.972.536
3.030.255
3.087.974
20
C-3-21-0
165.372
170.333
173.641
176.948
21
C-3-22-0
726.072
747.854
762.376
776.897
22
C-3-23-0
117.608
121.136
123.488
125.840
23
D-2-10-0

TULANG
996.390
1.026.282
1.046.209
1.066.137
24
D-2-11-0
PROSEDUR LIMPA
1.247.650
1.285.080
1.310.033
1.334.986
25
D-2-21-0
1.046.425
1.077.818
1.098.747
1.119.675
26
D-2-22-0
229.659
236.549
241.142
245.735
27
D-3-10-0
166.348
171.338
174.665
177.992
28
D-3-11-0
431.886
444.843
453.481
462.118
29
E-2-10-0
256.192
263.877
269.001
274.125
30
E-2-21-0
185.730
191.302
195.017
198.731
31
E-2-22-0
185.730
191.302
195.017
198.731

TYMUS
TYMUS
TULANG
PEMBENTUK DARAH
PARATIROID
THYROGLOSSAL
- 757 No
Kode
INA-CBG
32
E-3-10-0
33
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

ENDOKRIN
215.992
222.472
226.792
231.112
F-3-10-0
TERAPI SHOCK
301.302
310.341
316.367
322.393
34
F-5-10-0
369.193
380.268
387.652
395.036
35
F-5-11-0
TERAPI KELOMPOK
243.449
250.752
255.621
260.490
36
F-5-12-0
311.534
320.880
327.110
333.341
37
F-5-13-0
263.848
271.764
277.041
282.318
38
F-5-14-0
177.007
182.317
185.857
189.397
39
F-5-15-0
166.055
171.037
174.358
177.679
40
F-5-16-0
172.963
178.151
181.611
185.070
41
G-2-10-0
145.648
150.017
152.930
155.843
42
G-2-11-0
1.262.536
1.300.412
1.325.663
1.350.914
43
G-2-12-0

EKSTRAKRANIAL
1.829.726
1.884.618
1.921.212
1.957.807
44
G-2-13-0
448.873
462.339
471.316
480.294
45
G-2-21-0
818.668
843.228
859.601
875.975
46
G-2-22-0
743.011
765.301
780.161
795.022
47
G-2-31-0
1.226.033
1.262.814
1.287.334
1.311.855
48
G-2-32-0
628.463
647.317
659.886
672.456
49
G-3-10-0
249.441
256.924
261.913
266.902
50
G-3-11-0
332.208
342.174
348.818
355.462
51
G-3-12-0
544.328
560.658
571.544
582.431
52
G-3-13-0
544.390
560.722
571.610
582.497
53
H-2-21-0
714.431
735.864
750.153
764.441
54
H-2-22-0
185.730
191.302
195.017
198.731
55
H-2-23-0
185.730
191.302
195.017
198.731
56
H-2-31-0
1.183.396
1.218.898
1.242.565
1.266.233
57
H-2-32-0
123.164
126.859
129.322
131.785
58
H-2-33-0
185.730
191.302
195.017
198.731
59
H-2-34-0
530.900
546.827
557.445
568.063
60
H-2-35-0
174.944
180.192
183.691
187.190
61
H-2-36-0
944.305
972.634
991.520
1.010.406
62
H-2-37-0

1.005.254
1.035.412
1.055.517
1.075.622
63
H-3-10-0
349.755
360.248
367.243
374.238
64
H-3-11-0
183.932
189.450
193.129
196.808

AKUT
MENTAL
PROSEDUR KRANIOTOMI

MATA
MATA
MATA
MATA
MATA
- 758 No
Kode
INA-CBG
65
H-3-12-0
66
H-3-13-0
67
I-2-11-0
68
I-2-12-0
69
I-2-13-0
70
I-2-14-0
71
I-2-15-0
Deskripsi (INA-CBG)
MATA
TORASIK
ABDOMEN
PENGGANTIAN ALAT
DARAH VENA
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
192.035
197.796
201.636
205.477
186.454
192.048
195.777
199.506
2.150.214
2.214.720
2.257.725
2.300.729
1.511.835
1.557.190
1.587.427
1.617.663
1.921.451
1.979.095
2.017.524
2.055.953
3.400.560
3.502.576
3.570.588
3.638.599
204.503
210.638
214.728
218.818
2.147.884
2.212.320
2.255.278
2.298.235
708.096
729.338
743.500
757.662
72
I-2-16-0
73
I-2-17-0
74
I-2-21-0
1.657.861
1.707.597
1.740.754
1.773.911
75
I-2-22-0
1.561.166
1.608.001
1.639.225
1.670.448
76
I-2-23-0
319.488
329.073
335.462
341.852
77
I-2-31-0
2.484.766
2.559.309
2.609.004
2.658.700
78
I-2-32-0
3.249.197
3.346.672
3.411.656
3.476.640
79
I-2-41-0
2.178.626
2.243.985
2.287.558
2.331.130
80
I-2-42-0

LAIN
2.533.013
2.609.004
2.659.664
2.710.324
81
I-3-10-0
PROSEDUR RESUSITASI
321.544
331.190
337.621
344.052
82
I-3-11-0
169.710
174.801
178.195
181.590
83
I-3-12-0
986.290
1.015.879
1.035.605
1.055.331
84
I-3-13-0
323.936
333.654
340.133
346.611
85
I-3-14-0
207.632
213.861
218.013
222.166
183.932
189.450
193.129
196.808
1.138.791
1.172.955
1.195.730
1.218.506
183.573
189.080
192.752
196.423
925.093
952.845
971.347
989.849
1.199.928
1.235.926
1.259.924
1.283.923

PACU JANTUNG

KARDIOVASKULAR
PERNAFASAN
PENDEK
86
I-3-15-0
87
J-2-10-0
88
J-2-21-0
89
J-2-22-0
90
J-2-31-0
91
J-2-32-0
892.945
919.734
937.593
955.452
92
J-3-10-0
185.730
191.302
195.017
198.731
93
J-3-11-0

PADA DADA
524.840
540.586
551.082
561.579
94
J-3-12-0
202.771
208.854
212.909
216.965
95
J-3-13-0
298.428
307.381
313.350
319.318
96
J-3-14-0
316.814
326.318
332.655
338.991
- 759 No
Kode
INA-CBG
97
J-3-15-0
98
J-3-16-0
99
J-3-17-0
100
K-2-10-0
101
K-2-11-0
102
K-2-12-0

103
K-2-13-0
Deskripsi (INA-CBG)

PERNAFASAN
KECIL

FEMORALIS
USUS BESAR
ATAS
ATAS
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
277.821
286.155
291.712
297.268
316.814
326.318
332.655
338.991
185.730
191.302
195.017
198.731
534.595
550.633
561.325
572.017
1.141.578
1.175.826
1.198.657
1.221.489
876.309
902.598
920.124
937.650
1.426.240
1.469.027
1.497.552
1.526.077
185.730
191.302
195.017
198.731
185.730
191.302
195.017
198.731
2.387.075
2.458.687
2.506.429
2.554.170
802.652
826.732
842.785
858.838
185.730
191.302
195.017
198.731
104
K-2-14-0
105
K-2-21-0
106
K-2-22-0
107
K-2-31-0
108
K-2-32-0
109
K-2-41-0
884.138
910.662
928.345
946.027
110
K-2-42-0

252.609
260.187
265.240
270.292
111
K-2-51-0
585.883
603.460
615.177
626.895
112
K-2-52-0
319.488
329.073
335.462
341.852
113
K-2-53-0
185.730
191.302
195.017
198.731
114
K-3-10-0

GASTROINTESTINAL
353.432
364.035
371.104
378.172
115
K-3-11-0
212.482
218.856
223.106
227.355
116
K-3-12-0
215.483
221.948
226.257
230.567
117
K-3-13-0
185.730
191.302
195.017
198.731
497.761
512.694
522.649
532.604
240.376
247.587
252.394
257.202
318.513
328.068
334.439
340.809
1.095.060
1.127.911
1.149.813
1.171.714
701.925
722.983
737.022
751.060
316.814
326.318
332.655
338.991
319.488
329.073
335.462
341.852

GASTROINTESTINAL
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
118
K-3-14-0
119
K-3-15-0
120
K-3-16-0
121
L-2-21-0
122
L-2-22-0
123
L-2-31-0
124
L-2-32-0
125
L-2-41-0
956.669
985.369
1.004.502
1.023.636
126
L-2-42-0

214.565
221.002
225.294
229.585
127
L-2-51-0
1.432.283
1.475.252
1.503.897
1.532.543
L-2-52-0

1.095.744
1.128.616
1.150.531
1.172.446
128
- 760 No
Kode
INA-CBG
129
L-2-53-0
130
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

185.730
191.302
195.017
198.731
L-3-10-0
252.609
260.187
265.240
270.292
131
L-3-11-0
245.301
252.660
257.566
262.472
132
L-3-12-0
186.820
192.425
196.161
199.897
133
M-2-10-0
1.465.330
1.509.290
1.538.597
1.567.903
134
M-2-21-0
1.312.305
1.351.674
1.377.920
1.404.166
135
M-2-22-0
319.488
329.073
335.462
341.852
136
M-2-31-0
PROSEDUR BUNION
797.093
821.006
836.948
852.890
137
M-2-32-0
252.609
260.187
265.240
270.292
138
M-2-41-0

TULANG
252.609
260.187
265.240
270.292
139
M-2-42-0
87.056
89.668
91.409
93.150
140
M-2-51-0
185.730
191.302
195.017
198.731
141
M-2-52-0
185.730
191.302
195.017
198.731
142
M-2-61-0
PROSEDUR ARTROSKOPI
910.361
937.672
955.879
974.086
143
M-2-62-0
185.730
191.302
195.017
198.731
915.285
942.744
961.050
979.355
1.248.260
1.285.708
1.310.673
1.335.639
185.730
191.302
195.017
198.731
921.544
949.191
967.621
986.052
889.329
916.009
933.796
951.583

DAN WAJAH
PAHA
PAHA

TULANG
WAJAH
WAJAH
BAWAH
BAWAH
144
M-2-63-0
145
M-2-64-0
146
M-2-65-0
147
M-2-71-0
148
M-2-72-0
149
M-2-81-0
1.326.180
1.365.965
1.392.489
1.419.012
150
M-2-82-0
963.384
992.286
1.011.554
1.030.821
151
M-2-83-0
185.730
191.302
195.017
198.731
152
M-2-84-0
185.730
191.302
195.017
198.731
153
M-3-10-0
530.110
546.013
556.615
567.217
154
M-3-11-0
293.914
302.731
308.609
314.487
155
M-3-12-0
664.663
684.603
697.896
711.189
156
M-3-13-0
216.698
223.199
227.533
231.867
157
M-3-14-0

TERTUTUP
370.374
381.485
388.892
396.300
158
M-3-15-0
163.172
168.067
171.331
174.594
159
M-3-16-0

185.730
191.302
195.017
198.731
160
M-3-17-0
202.771
208.854
212.909
216.965
161
N-2-11-0
2.453.678
2.527.288
2.576.362
2.625.435

PERGELANGAN TANGAN
PERGELANGAN TANGAN
MUSKULOSKELETAL
SKELETAL
- 761 No
Kode
INA-CBG
162
N-2-12-0
163
N-2-21-0
164
N-2-22-0
165
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.419.428
1.462.011
1.490.400
1.518.788
1.411.946
1.454.305
1.482.544
1.510.783
319.488
329.073
335.462
341.852
N-2-23-0
319.488
329.073
335.462
341.852
166
N-2-24-0
1.032.478
1.063.452
1.084.102
1.104.751
167
N-2-31-0
869.179
895.254
912.638
930.022
168
N-2-32-0
319.488
329.073
335.462
341.852
169
N-2-41-0
319.488
329.073
335.462
341.852
170
N-2-42-0
540.315
556.525
567.331
578.138
171
N-3-10-0
319.488
329.073
335.462
341.852
172
N-3-11-0
370.172
381.278
388.681
396.085
173
N-3-12-0
286.049
294.630
300.351
306.072
174
N-3-13-0
319.488
329.073
335.462
341.852
175
N-3-14-0
274.902
283.149
288.647
294.145
176
N-3-15-0
704.918
726.066
740.164
754.262
177
O-7-10-0
117.691
121.222
123.575
125.929
178
O-7-11-0
648.155
667.600
680.563
693.526
179
O-7-12-0
236.015
243.096
247.816
252.536
180
O-7-13-0
131.167
135.102
137.725
140.348
181
P-9-10-0
174.944
180.192
183.691
187.190
182
P-9-11-0
174.944
180.192
183.691
187.190
183
P-9-12-0
174.944
180.192
183.691
187.190
184
P-9-13-0
174.944
180.192
183.691
187.190
185
P-9-14-0
174.944
180.192
183.691
187.190
186
P-9-15-0
111.513
114.858
117.088
119.319
187
P-9-16-0
174.944
180.192
183.691
187.190
188
P-9-17-0
174.191
179.417
182.901
186.385
189
Q-5-10-0
228.007
234.848
239.408
243.968
190
Q-5-11-0
170.885
176.012
179.430
182.847
191
Q-5-12-0
GIGI
150.614
155.132
158.144
161.157
192
Q-5-13-0
MEDICAL CHECK-UP
114.460
117.894
120.183
122.472
193
Q-5-14-0
125.943
129.722
132.240
134.759


DAN URETHRA
URETHRA
TRANSURETHRA
TRANSURETHRA
SALURAN KEMIH
KEMIH
KEMIH
PROSEDUR DIALISIS
CAESAR
VAGINAL/JALAN LAHIR

ASPIRASI
- 762 No
Kode
INA-CBG
194
Q-5-15-0
195
Q-5-16-0
196
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
86.611
89.209
90.942
92.674
VAKSINASI
97.891
100.827
102.785
104.743
Q-5-17-0
PASANG INFUS
84.673
87.213
88.906
90.600
197
Q-5-18-0
159.381
164.162
167.350
170.537
198
Q-5-19-0
178.178
183.523
187.087
190.651
199
Q-5-20-0
ABORSI MENGANCAM
119.427
123.010
125.398
127.787
200
Q-5-21-0
ABORSI
117.800
121.334
123.690
126.046
201
Q-5-22-0
125.943
129.722
132.240
134.759
202
Q-5-23-0
154.188
158.813
161.897
164.981
203
Q-5-24-0
105.308
108.467
110.573
112.680
204
Q-5-25-0
164.226
169.153
172.437
175.722
205
Q-5-26-0
BRONKIAL AKUT
232.450
239.424
244.073
248.722
206
Q-5-27-0
165.423
170.386
173.694
177.003
207
Q-5-28-0
134.236
138.264
140.948
143.633
208
Q-5-29-0

JANTUNG LAIN-LAIN
380.046
391.447
399.048
406.649
209
Q-5-30-0
440.432
453.645
462.453
471.262
210
Q-5-31-0
FRAKTUR
157.128
161.842
164.985
168.127
211
Q-5-32-0
SALURAN KEMIH AKUT
181.990
187.450
191.090
194.729
212
Q-5-33-0
HEMATOLOGI AKUT
190.543
196.259
200.070
203.881
213
Q-5-34-0
INFEKSI VIRUS HIV
270.680
278.800
284.214
289.627
214
Q-5-35-0
INFEKSI AKUT
306.943
316.152
322.291
328.430
215
Q-5-36-0
357.456
368.179
375.328
382.477
216
Q-5-37-0

SHOCK
182.321
187.790
191.437
195.083
217
Q-5-38-0
PARU AKUT
243.130
250.424
255.287
260.150
218
Q-5-39-0
155.586
160.253
163.365
166.477
219
Q-5-40-0
152.654
157.234
160.287
163.340
220
Q-5-41-0
211.328
217.668
221.895
226.121
221
Q-5-42-0
165.690
170.660
173.974
177.288
222
Q-5-43-0
238.603
245.761
250.533
255.305
223
Q-5-44-0
194.733
200.575
204.470
208.364
224
T-2-10-0

TERAPI DETOKSIKASI
101.005
104.035
106.055
108.075
225
U-2-10-0
1.348.022
1.388.463
1.415.423
1.442.384
226
U-2-11-0

LEHER
1.602.274
1.650.343
1.682.388
1.714.434
227
U-2-12-0
176.292
181.581
185.107
188.632
- 763 No
Kode
INA-CBG
228
U-2-13-0
229
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
231.123
238.057
242.679
247.302
U-2-14-0
429.322
442.202
450.788
459.375
230
U-2-15-0
243.931
251.249
256.128
261.007
231
U-2-21-0
284.142
292.666
298.349
304.032
232
U-2-22-0
548.985
565.455
576.434
587.414
233
U-2-23-0
719.348
740.928
755.315
769.702
234
U-2-24-0
606.254
624.442
636.567
648.692
235
U-2-25-0
231.123
238.057
242.679
247.302
236
U-2-31-0
185.730
191.302
195.017
198.731
237
U-2-32-0
231.123
238.057
242.679
247.302
238
U-3-10-0
220.966
227.595
232.014
236.434
239
U-3-11-0
234.597
241.635
246.327
251.019
240
U-3-12-0
103.738
106.851
108.925
111.000
241
U-3-13-0
228.025
234.866
239.427
243.987
242
U-3-14-0
209.508
215.793
219.984
224.174
243
U-3-15-0
182.710
188.191
191.845
195.499
244
U-3-16-0
PROSEDUR PADA GIGI
206.063
212.245
216.367
220.488
245
V-2-10-0

PROSTAT
2.010.387
2.070.699
2.110.907
2.151.114
246
V-2-11-0
226.721
233.522
238.057
242.591
723.497
745.202
759.672
774.142
319.488
329.073
335.462
341.852
319.488
329.073
335.462
341.852

(RHINOPLASTY)

RONGGA HIDUNG
TENGGOROKAN
PROSEDUR PADA PENIS

SKROTUM
SKROTUM
TRANSURETHRAL
247
V-2-12-0
248
V-2-13-0
249
V-2-14-0
250
V-2-15-0
SIRKUMSISI/SUNAT
174.944
180.192
183.691
187.190
251
V-3-10-0
364.857
375.802
383.100
390.397
252
V-3-11-0
771.861
795.017
810.454
825.891
253
V-3-12-0
445.616
458.984
467.897
476.809
254
W-2-10-0
163.172
168.067
171.331
174.594
255
W-2-11-0
417.007
429.518
437.858
446.198
256
W-2-12-0
771.861
795.017
810.454
825.891
257
W-2-13-0
123.793
127.507
129.982
132.458
258
W-2-21-0
1.551.647
1.598.196
1.629.229
1.660.262
259
W-2-22-0
163.172
168.067
171.331
174.594

PROSEDUR ABORSI
RAHIM & LEHER RAHIM
TERHALANG/TERGANGGU
TERHALANG/TERGANGGU
PANGGUL TERBUKA
PANGGUL TERBUKA
- 764 No
Kode
INA-CBG
260
W-2-23-0
Deskripsi (INA-CBG)
JALAN LAHIR
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
544.514
560.849
571.739
582.630
1.787.473
1.841.097
1.876.846
1.912.596
1.253.636
1.291.245
1.316.317
1.341.390
261
W-2-31-0
262
W-2-32-0
263
W-2-33-0
532.812
548.796
559.452
570.109
264
W-2-34-0
181.219
186.655
190.280
193.904
265
W-3-10-0
440.431
453.644
462.453
471.262
266
W-3-11-0
352.068
362.630
369.672
376.713
267
W-3-12-0
163.172
168.067
171.331
174.594
268
Z-3-10-0
1.847.327
1.902.747
1.939.693
1.976.640
269
Z-3-11-0

EMPEDU
1.411.946
1.454.305
1.482.544
1.510.783
270
Z-3-12-0
235.761
242.834
247.549
252.264
271
Z-3-13-0

LAIN-LAIN
1.438.678
1.481.838
1.510.611
1.539.385
272
Z-3-14-0
DIAGNOSTIK TIDUR
284.471
293.005
298.695
304.384
273
Z-3-15-0
185.730
191.302
195.017
198.731
274
Z-3-16-0

(MRI)
596.137
614.022
625.944
637.867
275
Z-3-17-0
PENGOBATAN NUKLIR
250.271
257.780
262.785
267.790
276
Z-3-18-0
CT-SCAN KEPALA
241.132
248.366
253.188
258.011
277
Z-3-19-0
CT SCAN LAIN-LAIN
250.971
258.500
263.520
268.539
278
Z-3-20-0
170.692
175.812
179.226
182.640
279
Z-3-21-0
163.172
168.067
171.331
174.594
280
Z-3-22-0
183.962
189.481
193.160
196.839
281
Z-3-23-0
191.612
197.361
201.193
205.025
282
Z-3-24-0
376.480
387.775
395.304
402.834
283
Z-3-25-0
167.684
172.714
176.068
179.422
284
Z-3-26-0
189.516
195.201
198.992
202.782
285
Z-3-27-0
PERAWATAN LUKA
180.936
186.364
189.983
193.602
286
Z-3-28-0
IMAGING PAYUDARA
185.730
191.302
195.017
198.731
287
Z-3-29-0
IMAGING LAIN-LAIN
535.308
551.367
562.073
572.779
288
Z-3-30-0
FOTOTERAPI
90.340
93.050
94.857
96.664
- 765 4. RUMAH SAKIT ORTOPEDIKELAS C

a. RawatInap
No
Kode
INA-CBG
A-4-10-i
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
SEPTIKEMIA RINGAN
1.594.924
1.642.772
1.674.670
1.706.569
A-4-10-ii
SEPTIKEMIA SEDANG
2.725.868
2.807.644
2.862.162
2.916.679
A-4-10-iii
SEPTIKEMIA BERAT
3.902.402
4.019.474
4.097.522
4.175.570
A-4-11-i
4.279.626
4.408.015
4.493.607
4.579.200
A-4-11-ii

SEDANG
6.611.528
6.809.873
6.942.104
7.074.335
A-4-11-iii
7.410.972
7.633.301
7.781.521
7.929.740
A-4-12-i
DEMAM RINGAN
1.532.986
1.578.975
1.609.635
1.640.295
A-4-12-ii
DEMAM SEDANG
2.407.908
2.480.145
2.528.303
2.576.461
A-4-12-iii
DEMAM BERAT
2.755.674
2.838.344
2.893.457
2.948.571
10
A-4-13-i
1.916.232
1.973.719
2.012.044
2.050.369
11
A-4-13-ii
2.299.479
2.368.463
2.414.453
2.460.442
12
A-4-13-iii
2.794.745
2.878.587
2.934.482
2.990.377
1.532.986
1.578.975
1.609.635
1.640.295
2.394.989
2.466.839
2.514.739
2.562.639
2.672.738
2.752.920
2.806.375
2.859.830

LAIN-LAIN RINGAN
LAIN-LAIN SEDANG
LAIN-LAIN BERAT
13
A-4-14-i
14
A-4-14-ii
15
A-4-14-iii
16
A-4-15-i
INFEKSI HIV RINGAN
2.299.479
2.368.463
2.414.453
2.460.442
17
A-4-15-ii
INFEKSI HIV SEDANG
3.449.218
3.552.695
3.621.679
3.690.664
18
A-4-15-iii
INFEKSI HIV BERAT
5.253.405
5.411.007
5.516.076
5.621.144
19
B-1-01-i
25.493.308
26.258.107
26.767.974
27.277.840
20
B-1-01-ii
28.125.935
28.969.713
29.532.231
30.094.750
21
B-1-01-iii
49.338.677
50.818.837
51.805.611
52.792.384
22
B-1-10-i
3.305.121
3.404.275
3.470.377
3.536.479
23
B-1-10-ii
8.423.040
8.675.731
8.844.192
9.012.653
24
B-1-10-iii
16.055.934
16.537.612
16.858.731
17.179.850
25
B-1-11-i
2.474.432
2.548.665
2.598.154
2.647.642
26
B-1-11-ii
6.211.058
6.397.390
6.521.611
6.645.832
27
B-1-11-iii
7.787.125
8.020.739
8.176.482
8.332.224
28
B-1-12-i
5.278.053
5.436.394
5.541.955
5.647.516
29
B-1-12-ii
11.312.158
11.651.523
11.877.766
12.104.009
30
B-1-12-iii
13.767.323
14.180.343
14.455.689
14.731.036
31
B-1-13-i
3.458.591
3.562.348
3.631.520
3.700.692

(RINGAN)
(SEDANG)
(BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT
LAIN-LAIN (RINGAN)
- 766 No
Kode
INA-CBG
32
B-1-13-ii
33
B-1-13-iii
34
B-1-14-i
35
B-1-14-ii
36
B-1-14-iii
37
B-4-10-i
38
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.633.542
5.802.548
5.915.219
6.027.890
8.305.422
8.554.584
8.720.693
8.886.801
4.696.523
4.837.418
4.931.349
5.025.279
5.223.481
5.380.185
5.484.655
5.589.125
8.171.515
8.416.660
8.580.091
8.743.521
1.314.016
1.353.436
1.379.716
1.405.997
B-4-10-ii
1.916.232
1.973.719
2.012.044
2.050.369
39
B-4-10-iii
3.208.401
3.304.653
3.368.821
3.432.989
40
B-4-11-i
3.172.526
3.267.702
3.331.152
3.394.603
41
B-4-11-ii
4.823.032
4.967.723
5.064.183
5.160.644
42
B-4-11-iii
5.194.573
5.350.410
5.454.301
5.558.193
43
B-4-12-i
2.783.674
2.867.184
2.922.858
2.978.531
44
B-4-12-ii
3.946.565
4.064.962
4.143.893
4.222.825
45
B-4-12-iii
7.500.355
7.725.366
7.875.373
8.025.380
46
B-4-13-i
2.299.479
2.368.463
2.414.453
2.460.442
47
B-4-13-ii
2.725.522
2.807.288
2.861.798
2.916.309
48
B-4-13-iii
4.845.307
4.990.666
5.087.573
5.184.479
49
B-4-14-i
2.410.653
2.482.972
2.531.185
2.579.398
50
B-4-14-ii
2.708.909
2.790.176
2.844.354
2.898.533
51
B-4-14-iii
3.579.026
3.686.396
3.757.977
3.829.557
52
C-4-10-i
2.452.252
2.525.819
2.574.864
2.623.909
53
C-4-10-ii
4.764.468
4.907.402
5.002.691
5.097.980
54
C-4-10-iii
LEUKEMIA AKUT BERAT
7.281.683
7.500.134
7.645.767
7.791.401
55
C-4-11-i
2.466.957
2.540.966
2.590.305
2.639.644
56
C-4-11-ii
3.065.972
3.157.951
3.219.270
3.280.590
57
C-4-11-iii
5.708.390
5.879.642
5.993.810
6.107.977
58
C-4-12-i
RADIOTERAPI RINGAN
1.532.986
1.578.975
1.609.635
1.640.295
59
C-4-12-ii
RADIOTERAPI SEDANG
4.622.306
4.760.975
4.853.421
4.945.867
60
C-4-12-iii
RADIOTERAPI BERAT
9.384.207
9.665.733
9.853.417
10.041.101
61
C-4-13-i
KEMOTERAPI RINGAN
1.532.986
1.578.975
1.609.635
1.640.295
62
C-4-13-ii
KEMOTERAPI SEDANG
3.065.972
3.157.951
3.219.270
3.280.590
63
C-4-13-iii
KEMOTERAPI BERAT
4.011.597
4.131.945
4.212.177
4.292.409
64
C-4-14-i

RINGAN
2.176.984
2.242.293
2.285.833
2.329.373

LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT

PANCREAS RINGAN
PANCREAS SEDANG
PANCREAS BERAT
(RINGAN)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT
- 767 No
Kode
INA-CBG
65
C-4-14-ii
66
C-4-14-iii
67
D-1-10-i
68
D-1-10-ii
69
D-1-10-iii
70
D-1-11-i
71
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.181.148
3.276.582
3.340.205
3.403.828
4.849.568
4.995.055
5.092.046
5.189.038
16.312.788
16.802.172
17.128.428
17.454.683
24.845.628
25.590.997
26.087.909
26.584.822
33.672.615
34.682.793
35.356.245
36.029.698
3.671.928
3.782.086
3.855.525
3.928.963
D-1-11-ii
9.577.063
9.864.374
10.055.916
10.247.457
72
D-1-11-iii
13.176.554
13.571.851
13.835.382
14.098.913
73
D-1-20-i
4.130.132
4.254.036
4.336.638
4.419.241
74
D-1-20-ii
9.292.796
9.571.580
9.757.436
9.943.292
75
D-1-20-iii
18.069.326
18.611.405
18.972.792
19.334.178
76
D-4-10-i
1.472.527
1.516.703
1.546.153
1.575.604
77
D-4-10-ii
2.973.309
3.062.509
3.121.975
3.181.441
78
D-4-10-iii
3.832.465
3.947.439
4.024.088
4.100.737
79
D-4-11-i
1.916.232
1.973.719
2.012.044
2.050.369
80
D-4-11-ii
3.533.012
3.639.002
3.709.663
3.780.323
81
D-4-11-iii
5.352.021
5.512.582
5.619.622
5.726.663
82
D-4-12-i
1.965.689
2.024.660
2.063.973
2.103.287
83
D-4-12-ii
2.726.604
2.808.402
2.862.934
2.917.466
84
D-4-12-iii
4.186.701
4.312.302
4.396.036
4.479.770
85
D-4-13-i
1.532.986
1.578.975
1.609.635
1.640.295
86
D-4-13-ii
2.299.479
2.368.463
2.414.453
2.460.442
87
D-4-13-iii
2.682.725
2.763.207
2.816.862
2.870.516
88
D-4-14-i
1.916.232
1.973.719
2.012.044
2.050.369
89
D-4-14-ii
4.312.436
4.441.809
4.528.058
4.614.306
90
D-4-14-iii
5.144.139
5.298.463
5.401.346
5.504.229
91
E-1-01-i
4.024.315
4.145.045
4.225.531
4.306.018
92
E-1-01-ii
5.271.470
5.429.614
5.535.044
5.640.473
93
E-1-01-iii
10.910.013
11.237.313
11.455.514
11.673.714
94
E-1-10-i
3.744.352
3.856.683
3.931.570
4.006.457
95
E-1-10-ii
4.544.765
4.681.108
4.772.003
4.862.898
96
E-1-10-iii
9.579.026
9.866.397
10.057.978
10.249.558
97
E-1-20-i

4.748.536
4.890.992
4.985.962
5.080.933

SEDANG
BERAT
TULANG RINGAN
TULANG SEDANG
TULANG BERAT


RINGAN
SEDANG
BERAT
- 768 No
Kode
INA-CBG
98
E-1-20-ii
99
E-1-20-iii
100
E-4-10-i
101
E-4-10-ii
102
E-4-10-iii
103
E-4-11-i
104
E-4-11-ii
105
E-4-11-iii
106
E-4-12-i
107
E-4-12-ii
108
E-4-12-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
6.359.896
6.550.693
6.677.891
6.805.089
14.091.733
14.514.485
14.796.320
15.078.154
1.948.457
2.006.911
2.045.880
2.084.849
2.984.549
3.074.086
3.133.777
3.193.467
5.209.330
5.365.610
5.469.797
5.573.983
1.790.484
1.844.198
1.880.008
1.915.817
3.387.287
3.488.906
3.556.652
3.624.398
5.585.793
5.753.367
5.865.083
5.976.799
2.107.856
2.171.091
2.213.248
2.255.406
3.449.218
3.552.695
3.621.679
3.690.664
5.541.579
5.707.827
5.818.658
5.929.490
2.256.625
2.324.323
2.369.456
2.414.588
3.874.640
3.990.880
4.068.372
4.145.865
6.704.106
6.905.230
7.039.312
7.173.394

RINGAN
SEDANG
BERAT

RINGAN
SEDANG
BERAT
109
E-4-13-i
110
E-4-13-ii
111
E-4-13-iii
112
F-4-10-i
SCHIZOFRENIA RINGAN
2.759.151
2.841.925
2.897.108
2.952.291
113
F-4-10-ii
SCHIZOFRENIA SEDANG
3.064.125
3.156.049
3.217.332
3.278.614
114
F-4-10-iii
SCHIZOFRENIA BERAT
4.536.505
4.672.600
4.763.331
4.854.061
115
F-4-11-i
2.543.268
2.619.567
2.670.432
2.721.297
116
F-4-11-ii
2.963.149
3.052.044
3.111.307
3.170.570
117
F-4-11-iii
DEPRESI MAYOR BERAT
3.799.840
3.913.835
3.989.832
4.065.829
1.241.967
1.279.226
1.304.065
1.328.904
1.641.665
1.690.915
1.723.748
1.756.581
3.561.316
3.668.156
3.739.382
3.810.609

IMPULSE RINGAN
IMPULSE SEDANG
IMPULSE BERAT
118
F-4-12-i
119
F-4-12-ii
120
F-4-12-iii
121
F-4-13-i
2.055.347
2.117.008
2.158.115
2.199.222
122
F-4-13-ii
2.721.808
2.803.462
2.857.899
2.912.335
123
F-4-13-iii
3.509.424
3.614.707
3.684.895
3.755.084
124
F-4-14-i
DEPRESI RINGAN
1.438.743
1.481.906
1.510.680
1.539.455
125
F-4-14-ii
DEPRESI SEDANG
1.845.480
1.900.844
1.937.754
1.974.663
126
F-4-14-iii
DEPRESI BERAT
2.483.176
2.557.671
2.607.334
2.656.998
127
F-4-15-i
1.710.584
1.761.901
1.796.113
1.830.325
128
F-4-15-ii
2.408.148
2.480.392
2.528.555
2.576.718
129
F-4-15-iii
3.028.555
3.119.411
3.179.982
3.240.554
F-4-16-i

3.684.263
3.794.791
3.868.476
3.942.161
130
- 769 No
Kode
INA-CBG
131
F-4-16-ii
132
F-4-16-iii
133
F-4-17-i
134
F-4-17-ii
135
F-4-17-iii
136
F-4-18-i
137
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.282.863
4.411.349
4.497.006
4.582.663
5.716.907
5.888.415
6.002.753
6.117.091
776.758
800.060
815.596
831.131
2.276.603
2.344.901
2.390.433
2.435.965
2.428.968
2.501.837
2.550.416
2.598.996
3.193.395
3.289.197
3.353.064
3.416.932
F-4-18-ii
3.513.636
3.619.045
3.689.318
3.759.591
138
F-4-18-iii
5.416.576
5.579.074
5.687.405
5.795.737
139
F-4-19-i
2.449.032
2.522.503
2.571.484
2.620.465
140
F-4-19-ii
3.136.049
3.230.131
3.292.852
3.355.572
141
F-4-19-iii
3.904.423
4.021.556
4.099.644
4.177.733
142
G-1-01-i
7.109.639
7.322.928
7.465.121
7.607.314
143
G-1-01-ii
12.033.921
12.394.938
12.635.617
12.876.295
144
G-1-01-iii
23.296.327
23.995.216
24.461.143
24.927.069
145
G-1-10-i
3.885.605
4.002.173
4.079.885
4.157.597
146
G-1-10-ii
5.485.508
5.650.074
5.759.784
5.869.494
147
G-1-10-iii
6.501.499
6.696.544
6.826.574
6.956.604
148
G-1-11-i
4.482.161
4.616.626
4.706.270
4.795.913
149
G-1-11-ii
9.204.456
9.480.590
9.664.679
9.848.768
150
G-1-11-iii
19.273.294
19.851.493
20.236.959
20.622.425
151
G-1-12-i
3.485.801
3.590.375
3.660.091
3.729.807
152
G-1-12-ii
7.980.394
8.219.806
8.379.414
8.539.022
153
G-1-12-iii
13.739.952
14.152.151
14.426.950
14.701.749
154
G-1-13-i
839.455
864.639
881.428
898.217
155
G-1-13-ii
2.254.684
2.322.324
2.367.418
2.412.512
156
G-1-13-iii
5.087.516
5.240.142
5.341.892
5.443.642
157
G-1-20-i
4.392.406
4.524.178
4.612.026
4.699.874
158
G-1-20-ii
5.934.284
6.112.313
6.230.998
6.349.684
159
G-1-20-iii
14.529.397
14.965.279
15.255.867
15.546.455
160
G-1-30-i
5.602.118
5.770.182
5.882.224
5.994.266
161
G-1-30-ii
14.622.066
15.060.727
15.353.169
15.645.610
162
G-1-30-iii
18.823.117
19.387.811
19.764.273
20.140.735
G-4-10-i

BELAKANG RINGAN
2.299.479
2.368.463
2.414.453
2.460.442
163

RINGAN
SEDANG
BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

RINGAN
SEDANG
BERAT
- 770 No
Kode
INA-CBG
164
G-4-10-ii
165
G-4-10-iii
166
G-4-11-i
167
G-4-11-ii
168
G-4-11-iii
169
G-4-12-i
170
G-4-12-ii
171
G-4-12-iii
172
G-4-13-i
173
G-4-13-ii
174
G-4-13-iii
175
G-4-14-i
176
G-4-14-ii
177
G-4-14-iii
178
G-4-15-i
179
G-4-15-ii
180
G-4-15-iii
181
G-4-16-i
182
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.682.725
2.763.207
2.816.862
2.870.516
4.488.357
4.623.008
4.712.775
4.802.542
4.154.906
4.279.553
4.362.651
4.445.749
4.819.691
4.964.281
5.060.675
5.157.069
7.063.340
7.275.240
7.416.507
7.557.773
3.107.504
3.200.729
3.262.879
3.325.029
3.915.455
4.032.918
4.111.227
4.189.537
5.686.732
5.857.334
5.971.068
6.084.803
1.728.994
1.780.864
1.815.444
1.850.024
2.682.725
2.763.207
2.816.862
2.870.516
3.171.362
3.266.503
3.329.930
3.393.358
3.162.073
3.256.935
3.320.176
3.383.418
5.202.677
5.358.757
5.462.811
5.566.864
6.513.870
6.709.286
6.839.563
6.969.841
2.299.479
2.368.463
2.414.453
2.460.442
2.915.221
3.002.678
3.060.983
3.119.287
4.412.866
4.545.252
4.633.510
4.721.767
1.916.232
1.973.719
2.012.044
2.050.369
G-4-16-ii
2.865.743
2.951.715
3.009.030
3.066.345
183
G-4-16-iii
5.200.811
5.356.836
5.460.852
5.564.868
184
G-4-17-i
2.998.989
3.088.959
3.148.938
3.208.918
185
G-4-17-ii
3.721.877
3.833.534
3.907.971
3.982.409
186
G-4-17-iii
6.237.897
6.425.034
6.549.792
6.674.550
187
G-4-18-i
2.299.479
2.368.463
2.414.453
2.460.442
188
G-4-18-ii
3.610.712
3.719.033
3.791.247
3.863.461
189
G-4-18-iii
3.825.181
3.939.937
4.016.440
4.092.944
190
G-4-19-i
2.097.408
2.160.330
2.202.278
2.244.226
191
G-4-19-ii
3.883.503
4.000.008
4.077.678
4.155.348
192
G-4-19-iii
5.792.953
5.966.742
6.082.601
6.198.460

BELAKANG SEDANG
BELAKANG BERAT
DEGENERATIF RINGAN
DEGENERATIF SEDANG
DEGENERATIF BERAT
RINGAN
SEDANG
BERAT
TRAUMATIK RINGAN
TRAUMATIK SEDANG
TRAUMATIK BERAT
DENGAN INFARK BERAT
TANPA INFARK RINGAN
TANPA INFARK SEDANG
TANPA INFARK BERAT

PERIFER RINGAN
PERIFER SEDANG
PERIFER BERAT
PERSARAFAN RINGAN
PERSARAFAN SEDANG
PERSARAFAN BERAT
RINGAN
SEDANG
- 771 No
Kode
INA-CBG
193
G-4-20-i
194
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.341.363
1.381.604
1.408.431
1.435.258
G-4-20-ii
1.904.736
1.961.879
1.999.973
2.038.068
195
G-4-20-iii
3.248.022
3.345.463
3.410.423
3.475.383
196
G-4-21-i
1.702.200
1.753.266
1.787.310
1.821.354
197
G-4-21-ii
3.525.427
3.631.189
3.701.698
3.772.207
198
G-4-21-iii
4.153.368
4.277.969
4.361.037
4.444.104
199
G-4-22-i
1.532.986
1.578.975
1.609.635
1.640.295
200
G-4-22-ii
1.916.232
1.973.719
2.012.044
2.050.369
201
G-4-22-iii
2.198.419
2.264.372
2.308.340
2.352.309
202
G-4-23-i
1.532.986
1.578.975
1.609.635
1.640.295
203
G-4-23-ii
1.916.232
1.973.719
2.012.044
2.050.369
204
G-4-23-iii
2.739.118
2.821.292
2.876.074
2.930.857
205
G-4-24-i
1.532.986
1.578.975
1.609.635
1.640.295
206
G-4-24-ii
1.916.232
1.973.719
2.012.044
2.050.369
207
G-4-24-iii
TRAUMA KEPALA BERAT
4.026.755
4.147.558
4.228.093
4.308.628
208
G-4-25-i
GEGAR OTAK RINGAN
1.532.986
1.578.975
1.609.635
1.640.295
209
G-4-25-ii
GEGAR OTAK SEDANG
1.916.232
1.973.719
2.012.044
2.050.369
210
G-4-25-iii
GEGAR OTAK BERAT
2.392.780
2.464.564
2.512.419
2.560.275
211
G-4-26-i
2.529.988
2.605.887
2.656.487
2.707.087
212
G-4-26-ii
2.869.090
2.955.163
3.012.545
3.069.927
213
G-4-26-iii
5.120.947
5.274.576
5.376.995
5.479.414
214
H-1-20-i
2.413.126
2.485.519
2.533.782
2.582.045
215
H-1-20-ii
4.400.608
4.532.626
4.620.638
4.708.650
216
H-1-20-iii
5.984.552
6.164.088
6.283.779
6.403.470
217
H-1-30-i
2.362.680
2.433.560
2.480.814
2.528.067
218
H-1-30-ii
2.693.455
2.774.259
2.828.128
2.881.997
219
H-1-30-iii
4.493.932
4.628.750
4.718.629
4.808.508
220
H-4-10-i
2.299.479
2.368.463
2.414.453
2.460.442
221
H-4-10-ii
3.832.465
3.947.439
4.024.088
4.100.737
222
H-4-10-iii
6.248.049
6.435.491
6.560.452
6.685.413
223
H-4-11-i
1.714.641
1.766.080
1.800.373
1.834.666
224
H-4-11-ii
1.892.634
1.949.413
1.987.266
2.025.118
225
H-4-11-iii
2.501.519
2.576.564
2.626.595
2.676.625
226
H-4-12-i
2.378.995
2.450.365
2.497.945
2.545.525

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)

RINGAN
SEDANG
- 772 No
Kode
INA-CBG
227
H-4-12-ii
228
H-4-12-iii
229
I-1-01-i
230
I-1-01-ii
231
I-1-01-iii
232
I-1-02-i
233
I-1-02-ii
234
I-1-02-iii
235
I-1-03-i
236
I-1-03-ii
237
I-1-03-iii
238
I-1-04-i
239
I-1-04-ii
240
I-1-04-iii
241
I-1-05-i
242
I-1-05-ii
243
I-1-05-iii
244
I-1-06-i
245
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.222.505
3.319.180
3.383.630
3.448.080
5.376.530
5.537.826
5.645.356
5.752.887
33.072.334
34.064.505
34.725.951
35.387.398
33.800.098
34.814.101
35.490.103
36.166.105
53.352.807
54.953.391
56.020.447
57.087.503
18.348.341
18.898.791
19.265.758
19.632.725
23.669.359
24.379.440
24.852.827
25.326.215
29.173.862
30.049.078
30.632.555
31.216.032
11.299.561
11.638.548
11.864.539
12.090.530
15.487.993
15.952.633
16.262.393
16.572.153
22.715.724
23.397.195
23.851.510
24.305.824
15.096.547
15.549.444
15.851.375
16.153.306
19.391.783
19.973.536
20.361.372
20.749.208
41.339.255
42.579.433
43.406.218
44.233.003
24.284.569
25.013.106
25.498.797
25.984.488
29.141.482
30.015.727
30.598.556
31.181.386
40.098.496
41.301.451
42.103.420
42.905.390
12.536.208
12.912.294
13.163.019
13.413.743
I-1-06-ii
18.920.114
19.487.717
19.866.120
20.244.522
246
I-1-06-iii
22.241.100
22.908.333
23.353.155
23.797.977
247
I-1-07-i
16.486.063
16.980.645
17.310.366
17.640.087
248
I-1-07-ii
20.338.908
20.949.075
21.355.853
21.762.631
249
I-1-07-iii
22.189.616
22.855.305
23.299.097
23.742.889
250
I-1-11-i
3.136.051
3.230.133
3.292.854
3.355.575
251
I-1-11-ii
3.486.975
3.591.585
3.661.324
3.731.064
252
I-1-11-iii
4.640.101
4.779.304
4.872.106
4.964.908
253
I-1-12-i
8.776.530
9.039.825
9.215.356
9.390.887
254
I-1-12-ii
12.177.845
12.543.180
12.786.737
13.030.294
255
I-1-12-iii
16.985.218
17.494.775
17.834.479
18.174.184

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
KATETERISASI RINGAN
KATETERISASI SEDANG
KATETERISASI BERAT
RINGAN
SEDANG
BERAT

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
- 773 No
Kode
INA-CBG
256
I-1-13-i
257
I-1-13-ii
258
I-1-13-iii
259
I-1-14-i
260
I-1-14-ii
261
I-1-14-iii
262
I-1-15-i
263
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.162.664
5.317.544
5.420.798
5.524.051
6.006.444
6.186.637
6.306.766
6.426.895
11.990.984
12.350.713
12.590.533
12.830.353
18.887.998
19.454.638
19.832.398
20.210.158
23.475.083
24.179.335
24.648.837
25.118.339
30.760.453
31.683.267
32.298.476
32.913.685
4.053.241
4.174.838
4.255.903
4.336.967
I-1-15-ii
10.841.595
11.166.843
11.383.675
11.600.507
264
I-1-15-iii
56.117.717
57.801.248
58.923.602
60.045.957
265
I-1-16-i
8.094.856
8.337.702
8.499.599
8.661.496
266
I-1-16-ii
21.046.626
21.678.025
22.098.957
22.519.890
267
I-1-16-iii
24.276.767
25.005.070
25.490.605
25.976.140
268
I-1-17-i
2.843.058
2.928.349
2.985.210
3.042.072
269
I-1-17-ii
5.889.003
6.065.673
6.183.453
6.301.233
270
I-1-17-iii
34.140.856
35.165.082
35.847.899
36.530.716
271
I-1-20-i
4.594.771
4.732.615
4.824.510
4.916.405
272
I-1-20-ii
7.591.279
7.819.018
7.970.843
8.122.669
273
I-1-20-iii
15.372.064
15.833.225
16.140.667
16.448.108
274
I-1-30-i
9.183.656
9.459.166
9.642.839
9.826.512
275
I-1-30-ii
19.103.861
19.676.976
20.059.054
20.441.131
276
I-1-30-iii
29.604.045
30.492.167
31.084.248
31.676.329
277
I-1-40-i
13.524.829
13.930.574
14.201.070
14.471.567
278
I-1-40-ii
18.326.306
18.876.095
19.242.621
19.609.147
279
I-1-40-iii
22.666.402
23.346.394
23.799.722
24.253.050
280
I-4-10-i
3.933.413
4.051.416
4.130.084
4.208.752
281
I-4-10-ii
6.210.930
6.397.258
6.521.476
6.645.695
282
I-4-10-iii
8.959.808
9.228.603
9.407.799
9.586.995
283
I-4-11-i
4.664.000
4.803.920
4.897.200
4.990.479
284
I-4-11-ii
5.748.697
5.921.158
6.036.132
6.151.106

KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

DARAH VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
- 774 No
Kode
INA-CBG
285
I-4-11-iii
286
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
9.327.246
9.607.063
9.793.608
9.980.153
I-4-12-i
4.085.179
4.207.734
4.289.438
4.371.141
287
I-4-12-ii
5.829.538
6.004.425
6.121.015
6.237.606
288
I-4-12-iii
7.072.050
7.284.212
7.425.653
7.567.094
3.669.613
3.779.702
3.853.094
3.926.486
5.331.200
5.491.135
5.597.759
5.704.383
9.964.408
10.263.341
10.462.629
10.661.917

VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
289
I-4-13-i
290
I-4-13-ii
291
I-4-13-iii
292
I-4-14-i
2.282.161
2.350.625
2.396.269
2.441.912
293
I-4-14-ii
2.670.465
2.750.579
2.803.989
2.857.398
294
I-4-14-iii
4.138.333
4.262.483
4.345.250
4.428.016
3.065.972
3.157.951
3.219.270
3.280.590
4.806.636
4.950.835
5.046.967
5.143.100
5.478.408
5.642.760
5.752.328
5.861.897

295
I-4-15-i
296
I-4-15-ii
297
I-4-15-iii
298
I-4-16-i
2.299.479
2.368.463
2.414.453
2.460.442
299
I-4-16-ii
3.726.663
3.838.463
3.912.996
3.987.530
300
I-4-16-iii
4.694.934
4.835.782
4.929.681
5.023.579
301
I-4-17-i
HIPERTENSI RINGAN
2.253.767
2.321.380
2.366.456
2.411.531
302
I-4-17-ii
HIPERTENSI SEDANG
3.074.549
3.166.785
3.228.276
3.289.767
303
I-4-17-iii
HIPERTENSI BERAT
3.593.530
3.701.336
3.773.207
3.845.077
3.319.152
3.418.726
3.485.109
3.551.492
5.084.718
5.237.260
5.338.954
5.440.649
6.855.015
7.060.666
7.197.766
7.334.866
2.597.671
2.675.601
2.727.555
2.779.508
4.216.943
4.343.451
4.427.790
4.512.129
4.830.374
4.975.285
5.071.893
5.168.500

RINGAN
SEDANG
KONGENITAL BERAT
RINGAN
SEDANG
BERAT
304
I-4-18-i
305
I-4-18-ii
306
I-4-18-iii
307
I-4-19-i
308
I-4-19-ii
309
I-4-19-iii
310
I-4-20-i
3.152.642
3.247.221
3.310.274
3.373.327
311
I-4-20-ii
3.632.079
3.741.042
3.813.683
3.886.325
312
I-4-20-iii
4.820.374
4.964.985
5.061.392
5.157.800
313
I-4-21-i
4.192.504
4.318.279
4.402.129
4.485.979
314
I-4-21-ii
5.229.876
5.386.773
5.491.370
5.595.968
315
I-4-21-iii
7.134.660
7.348.700
7.491.393
7.634.087
316
I-4-22-i
2.491.102
2.565.835
2.615.657
2.665.479
317
I-4-22-ii
2.870.495
2.956.610
3.014.020
3.071.430
- 775 No
Kode
INA-CBG
318
I-4-22-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.187.975
4.313.614
4.397.373
4.481.133
1.887.150
1.943.765
1.981.508
2.019.251
2.316.986
2.386.495
2.432.835
2.479.175
4.527.179
4.662.994
4.753.538
4.844.081
2.464.952
2.538.901
2.588.200
2.637.499
6.154.303
6.338.932
6.462.018
6.585.104
7.781.005
8.014.435
8.170.055
8.325.675
19.859.361
20.455.142
20.852.329
21.249.516
21.215.683
21.852.154
22.276.468
22.700.781
36.247.120
37.334.533
38.059.476
38.784.418
10.151.712
10.456.263
10.659.297
10.862.331
10.875.188
11.201.444
11.418.947
11.636.451
16.070.429
16.552.542
16.873.950
17.195.359
3.961.345
4.080.185
4.159.412
4.238.639
9.568.087
9.855.129
10.046.491
10.237.853
16.941.474
17.449.718
17.788.547
18.127.377
3.423.869
3.526.585
3.595.063
3.663.540
4.979.748
5.129.140
5.228.735
5.328.330
7.488.002
7.712.642
7.862.402
8.012.162
2.308.904
2.378.171
2.424.349
2.470.527
10.325.329
10.635.089
10.841.595
11.048.102
31.140.739
32.074.961
32.697.776
33.320.590
319
I-4-23-i
320
I-4-23-ii
321
I-4-23-iii
322
I-4-24-i
323
I-4-24-ii
324
I-4-24-iii
325
J-1-01-i
326
J-1-01-ii
327
J-1-01-iii
328
J-1-02-i
329
J-1-02-ii
330
J-1-02-iii
331
J-1-10-i
332
J-1-10-ii
333
J-1-10-iii
334
J-1-20-i
335
J-1-20-ii
336
J-1-20-iii
337
J-1-30-i
338
J-1-30-ii
339
J-1-30-iii
340
J-4-10-i
2.433.298
2.506.297
2.554.963
2.603.629
341
J-4-10-ii
3.479.324
3.583.703
3.653.290
3.722.876
342
J-4-10-iii
5.263.697
5.421.608
5.526.882
5.632.156
343
J-4-11-i
1.681.139
1.731.574
1.765.196
1.798.819
344
J-4-11-ii
2.340.108
2.410.311
2.457.113
2.503.915
345
J-4-11-iii
3.353.434
3.454.037
3.521.106
3.588.174
346
J-4-12-i
EMBOLI PARU RINGAN
2.347.569
2.417.996
2.464.947
2.511.899
347
J-4-12-ii
EMBOLI PARU SEDANG
3.040.021
3.131.222
3.192.022
3.252.823
348
J-4-12-iii
EMBOLI PARU BERAT
4.059.641
4.181.430
4.262.623
4.343.816
- 776 No
Kode
INA-CBG
349
J-4-13-i
350
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.960.160
4.078.965
4.158.168
4.237.372
J-4-13-ii
5.821.436
5.996.079
6.112.508
6.228.936
351
J-4-13-iii
9.464.783
9.748.727
9.938.023
10.127.318
352
J-4-14-i
TUMOR PARU RINGAN
2.698.724
2.779.686
2.833.660
2.887.635
353
J-4-14-ii
TUMOR PARU SEDANG
4.520.732
4.656.354
4.746.769
4.837.184
354
J-4-14-iii
TUMOR PARU BERAT
5.374.921
5.536.169
5.643.667
5.751.166
2.362.630
2.433.509
2.480.762
2.528.014
3.326.724
3.426.526
3.493.060
3.559.595
4.180.454
4.305.868
4.389.477
4.473.086
1.916.232
1.973.719
2.012.044
2.050.369
2.777.481
2.860.805
2.916.355
2.971.904
4.839.354
4.984.535
5.081.322
5.178.109

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
355
J-4-15-i
356
J-4-15-ii
357
J-4-15-iii
358
J-4-16-i
359
J-4-16-ii
360
J-4-16-iii
361
J-4-17-i
1.934.271
1.992.299
2.030.984
2.069.670
362
J-4-17-ii
2.625.367
2.704.128
2.756.635
2.809.142
363
J-4-17-iii
4.227.460
4.354.283
4.438.833
4.523.382
364
J-4-18-i
1.532.986
1.578.975
1.609.635
1.640.295
365
J-4-18-ii
2.107.856
2.171.091
2.213.248
2.255.406
366
J-4-18-iii
2.219.443
2.286.026
2.330.415
2.374.804
367
J-4-19-i
2.682.725
2.763.207
2.816.862
2.870.516
368
J-4-19-ii
3.326.699
3.426.500
3.493.034
3.559.568
369
J-4-19-iii
4.803.204
4.947.300
5.043.365
5.139.429
370
J-4-20-i
2.705.818
2.786.993
2.841.109
2.895.225
371
J-4-20-ii
3.583.743
3.691.256
3.762.931
3.834.605
372
J-4-20-iii
7.394.510
7.616.345
7.764.236
7.912.126
1.532.986
1.578.975
1.609.635
1.640.295
3.782.156
3.895.621
3.971.264
4.046.907
5.394.592
5.556.429
5.664.321
5.772.213
4.130.132
4.254.036
4.336.638
4.419.241
6.312.201
6.501.567
6.627.811
6.754.055
7.392.674
7.614.455
7.762.308
7.910.162

USUS BESAR (RINGAN)
USUS BESAR (SEDANG)
USUS BESAR (BERAT)
373
J-4-21-i
374
J-4-21-ii
375
J-4-21-iii
376
K-1-10-i
377
K-1-10-ii
378
K-1-10-iii
379
K-1-11-i
3.889.120
4.005.793
4.083.576
4.161.358
380
K-1-11-ii
5.105.945
5.259.123
5.361.242
5.463.361
381
K-1-11-iii
12.957.883
13.346.620
13.605.778
13.864.935
- 777 No
Kode
INA-CBG
382
K-1-12-i
383
K-1-12-ii
384
K-1-12-iii
385
K-1-13-i
386
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.092.049
2.154.810
2.196.651
2.238.492
2.726.587
2.808.384
2.862.916
2.917.448
5.423.754
5.586.467
5.694.942
5.803.417
2.376.281
2.447.569
2.495.095
2.542.620
K-1-13-ii
4.150.680
4.275.200
4.358.214
4.441.227
387
K-1-13-iii
4.439.002
4.572.172
4.660.952
4.749.732
388
K-1-14-i
3.840.210
3.955.417
4.032.221
4.109.025
389
K-1-14-ii
4.510.762
4.646.085
4.736.300
4.826.515
390
K-1-14-iii
11.106.804
11.440.008
11.662.144
11.884.280
391
K-1-20-i
7.451.134
7.674.668
7.823.691
7.972.714
392
K-1-20-ii
10.399.819
10.711.813
10.919.809
11.127.806
393
K-1-20-iii
22.214.504
22.880.939
23.325.229
23.769.519
394
K-1-30-i
4.904.707
5.051.849
5.149.943
5.248.037
395
K-1-30-ii
8.260.263
8.508.071
8.673.276
8.838.482
396
K-1-30-iii
14.088.113
14.510.756
14.792.519
15.074.281
397
K-1-40-i
4.927.371
5.075.192
5.173.739
5.272.287
398
K-1-40-ii
5.422.082
5.584.745
5.693.186
5.801.628
399
K-1-40-iii
8.992.001
9.261.761
9.441.601
9.621.441
400
K-1-50-i
3.758.395
3.871.147
3.946.315
4.021.483
401
K-1-50-ii
4.867.299
5.013.318
5.110.664
5.208.010
402
K-1-50-iii
PROSEDUR ANAL BERAT
6.910.270
7.117.578
7.255.783
7.393.989
403
K-4-10-i
2.846.714
2.932.115
2.989.050
3.045.984
404
K-4-10-ii
3.406.260
3.508.448
3.576.573
3.644.699
405
K-4-10-iii
12.879.976
13.266.375
13.523.975
13.781.574
406
K-4-11-i
1.532.986
1.578.975
1.609.635
1.640.295
407
K-4-11-ii
2.299.479
2.368.463
2.414.453
2.460.442
408
K-4-11-iii
4.178.982
4.304.351
4.387.931
4.471.510
409
K-4-12-i
1.532.986
1.578.975
1.609.635
1.640.295
410
K-4-12-ii
2.508.135
2.583.379
2.633.542
2.683.704
411
K-4-12-iii
6.019.345
6.199.926
6.320.313
6.440.699
412
K-4-13-i
2.299.479
2.368.463
2.414.453
2.460.442
413
K-4-13-ii
2.978.391
3.067.743
3.127.311
3.186.879


RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)

(RINGAN)
(SEDANG)
- 778 No
Kode
INA-CBG
414
K-4-13-iii
415
K-4-14-i
416
K-4-14-ii
417
K-4-14-iii
418
K-4-15-i
419
K-4-15-ii
420
K-4-15-iii
421
K-4-16-i
422
K-4-16-ii
423
K-4-16-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.871.345
5.017.485
5.114.912
5.212.339
1.916.232
1.973.719
2.012.044
2.050.369
2.593.421
2.671.223
2.723.092
2.774.960
3.922.796
4.040.480
4.118.936
4.197.392
1.916.232
1.973.719
2.012.044
2.050.369
3.603.040
3.711.131
3.783.192
3.855.252
5.126.477
5.280.271
5.382.801
5.485.330
1.916.232
1.973.719
2.012.044
2.050.369
2.299.479
2.368.463
2.414.453
2.460.442
3.073.832
3.166.047
3.227.523
3.289.000
1.532.986
1.578.975
1.609.635
1.640.295
2.449.434
2.522.917
2.571.905
2.620.894
3.259.946
3.357.744
3.422.943
3.488.142
1.673.355
1.723.555
1.757.022
1.790.490
2.606.229
2.684.416
2.736.541
2.788.665
3.030.442
3.121.355
3.181.964
3.242.573
17.179.814
17.695.209
18.038.805
18.382.401
17.811.636
18.345.985
18.702.218
19.058.451
27.381.573
28.203.020
28.750.652
29.298.283
7.227.730
7.444.562
7.589.117
7.733.671
11.287.111
11.625.724
11.851.466
12.077.209
11.904.380
12.261.512
12.499.599
12.737.687
3.146.287
3.240.676
3.303.601
3.366.527
7.081.348
7.293.788
7.435.415
7.577.042
11.849.688
12.205.179
12.442.173
12.679.167

RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
424
K-4-17-i
425
K-4-17-ii
426
K-4-17-iii
427
K-4-18-i
428
K-4-18-ii
429
K-4-18-iii
430
L-1-20-i
431
L-1-20-ii
432
L-1-20-iii
433
L-1-30-i
434
L-1-30-ii
435
L-1-30-iii
436
L-1-40-i
437
L-1-40-ii
438
L-1-40-iii
439
L-1-50-i
5.162.664
5.317.544
5.420.798
5.524.051
440
L-1-50-ii
9.292.796
9.571.580
9.757.436
9.943.292
441
L-1-50-iii
11.236.305
11.573.394
11.798.120
12.022.847
442
L-4-10-i
2.299.479
2.368.463
2.414.453
2.460.442
443
L-4-10-ii
2.887.699
2.974.330
3.032.084
3.089.838
444
L-4-10-iii
5.943.201
6.121.497
6.240.361
6.359.225
445
L-4-11-i
2.381.791
2.453.244
2.500.880
2.548.516
- 779 No
Kode
INA-CBG
446
L-4-11-ii
447
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.263.012
3.360.902
3.426.162
3.491.422
L-4-11-iii
8.848.880
9.114.346
9.291.324
9.468.301
448
L-4-12-i
2.351.247
2.421.784
2.468.809
2.515.834
449
L-4-12-ii
3.694.834
3.805.679
3.879.575
3.953.472
450
L-4-12-iii
5.983.651
6.163.160
6.282.833
6.402.506
451
L-4-13-i
1.580.619
1.628.038
1.659.650
1.691.263
452
L-4-13-ii
1.822.547
1.877.224
1.913.675
1.950.126
453
L-4-13-iii
2.733.963
2.815.982
2.870.662
2.925.341
454
L-4-14-i
1.532.986
1.578.975
1.609.635
1.640.295
455
L-4-14-ii
2.299.479
2.368.463
2.414.453
2.460.442
456
L-4-14-iii
3.937.304
4.055.423
4.134.169
4.212.915
457
M-1-01-i
7.473.904
7.698.121
7.847.599
7.997.077
458
M-1-01-ii
8.342.085
8.592.348
8.759.190
8.926.031
459
M-1-01-iii
11.718.370
12.069.921
12.304.288
12.538.656
460
M-1-02-i
4.774.803
4.918.048
5.013.544
5.109.040
461
M-1-02-ii
7.839.320
8.074.499
8.231.285
8.388.072
462
M-1-02-iii
14.196.648
14.622.548
14.906.481
15.190.414
12.829.229
13.214.106
13.470.691
13.727.275
15.409.736
15.872.028
16.180.222
16.488.417
16.004.260
16.484.388
16.804.473
17.124.558
3.149.795
3.244.289
3.307.284
3.370.280
4.038.004
4.159.144
4.239.904
4.320.664
5.052.801
5.204.385
5.305.441
5.406.497
4.906.775
5.053.979
5.152.114
5.250.250
5.670.917
5.841.045
5.954.463
6.067.882
9.659.117
9.948.890
10.142.073
10.335.255
6.004.707
6.184.849
6.304.943
6.425.037
8.044.431
8.285.764
8.446.653
8.607.542
16.387.270
16.878.888
17.206.633
17.534.378
3.385.142
3.486.696
3.554.399
3.622.101
12.579.099
12.956.472
13.208.054
13.459.636
15.690.388
16.161.099
16.474.907
16.788.715
463
M-1-03-i
464
M-1-03-ii
465
M-1-03-iii
466
M-1-04-i
467
M-1-04-ii
468
M-1-04-iii
469
M-1-05-i
470
M-1-05-ii
471
M-1-05-iii
472
M-1-07-i
473
M-1-07-ii
474
M-1-07-iii
475
M-1-10-i
476
M-1-10-ii
477
M-1-10-iii


TULANG WAJAH RINGAN
TULANG WAJAH SEDANG
TULANG WAJAH BERAT
- 780 No
Kode
INA-CBG
478
M-1-20-i
479
M-1-20-ii
480
M-1-20-iii
481
M-1-30-i
482
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.348.780
3.449.243
3.516.219
3.583.194
4.776.052
4.919.334
5.014.855
5.110.376
9.291.438
9.570.181
9.756.010
9.941.839
2.003.071
2.063.163
2.103.224
2.143.286
M-1-30-ii
4.138.854
4.263.019
4.345.797
4.428.574
483
M-1-30-iii
PROSEDUR KAKI BERAT
6.174.297
6.359.526
6.483.012
6.606.498
484
M-1-40-i
2.243.783
2.311.097
2.355.972
2.400.848
485
M-1-40-ii
4.130.132
4.254.036
4.336.638
4.419.241
486
M-1-40-iii
7.227.730
7.444.562
7.589.117
7.733.671
487
M-1-50-i
2.680.463
2.760.877
2.814.486
2.868.096
488
M-1-50-ii
5.395.836
5.557.711
5.665.628
5.773.544
489
M-1-50-iii
8.260.263
8.508.071
8.673.276
8.838.482
2.022.904
2.083.591
2.124.049
2.164.507
4.049.867
4.171.363
4.252.360
4.333.358
7.048.201
7.259.647
7.400.611
7.541.575
2.709.878
2.791.174
2.845.372
2.899.569
5.529.493
5.695.378
5.805.968
5.916.558
8.914.211
9.181.637
9.359.922
9.538.206


RINGAN
SEDANG
BERAT

SELAIN KAKI (BERAT)
490
M-1-60-i
491
M-1-60-ii
492
M-1-60-iii
493
M-1-70-i
494
M-1-70-ii
495
M-1-70-iii
496
M-1-80-i
2.183.428
2.248.931
2.292.600
2.336.268
497
M-1-80-ii
3.300.897
3.399.924
3.465.942
3.531.960
498
M-1-80-iii
7.599.520
7.827.506
7.979.496
8.131.487
499
M-4-10-i
1.532.986
1.578.975
1.609.635
1.640.295
500
M-4-10-ii
2.299.479
2.368.463
2.414.453
2.460.442
501
M-4-10-iii
FRAKTUR FEMUR BERAT
4.480.031
4.614.432
4.704.032
4.793.633
502
M-4-11-i
1.916.232
1.973.719
2.012.044
2.050.369
503
M-4-11-ii
4.198.415
4.324.367
4.408.336
4.492.304
504
M-4-11-iii
7.452.088
7.675.651
7.824.693
7.973.734
505
M-4-12-i
1.532.986
1.578.975
1.609.635
1.640.295
506
M-4-12-ii
2.789.266
2.872.944
2.928.729
2.984.515
507
M-4-12-iii
5.038.862
5.190.028
5.290.805
5.391.583
508
M-4-13-i
2.552.754
2.629.337
2.680.392
2.731.447

PANGGUL RINGAN
PANGGUL SEDANG
PANGGUL BERAT
PELVIS RINGAN
PELVIS SEDANG
PELVIS BERAT
- 781 No
Kode
INA-CBG
509
M-4-13-ii
510
M-4-13-iii
511
M-4-14-i
512
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.832.465
3.947.439
4.024.088
4.100.737
7.593.804
7.821.618
7.973.494
8.125.370
2.906.441
2.993.634
3.051.763
3.109.892
M-4-14-ii
3.590.467
3.698.181
3.769.990
3.841.799
513
M-4-14-iii
OSTEOMIELITIS BERAT
5.378.132
5.539.476
5.647.038
5.754.601
514
M-4-15-i
1.725.427
1.777.190
1.811.698
1.846.207
515
M-4-15-ii
2.300.715
2.369.736
2.415.751
2.461.765
516
M-4-15-iii
6.515.190
6.710.646
6.840.950
6.971.253
517
M-4-16-i
1.916.232
1.973.719
2.012.044
2.050.369
518
M-4-16-ii
3.065.972
3.157.951
3.219.270
3.280.590
519
M-4-16-iii
5.142.401
5.296.673
5.399.522
5.502.370
1.916.232
1.973.719
2.012.044
2.050.369
2.682.725
2.763.207
2.816.862
2.870.516
3.746.568
3.858.965
3.933.897
4.008.828
2.026.057
2.086.839
2.127.360
2.167.881
3.065.972
3.157.951
3.219.270
3.280.590
3.436.074
3.539.157
3.607.878
3.676.600
1.506.401
1.551.593
1.581.721
1.611.849
2.537.261
2.613.379
2.664.124
2.714.870
4.955.459
5.104.123
5.203.232
5.302.341
1.532.986
1.578.975
1.609.635
1.640.295
2.299.479
2.368.463
2.414.453
2.460.442
2.548.365
2.624.815
2.675.783
2.726.750
1.532.986
1.578.975
1.609.635
1.640.295
1.916.232
1.973.719
2.012.044
2.050.369
4.399.560
4.531.546
4.619.538
4.707.529

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
RINGAN
SEDANG
BERAT
ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
520
M-4-17-i
521
M-4-17-ii
522
M-4-17-iii
523
M-4-18-i
524
M-4-18-ii
525
M-4-18-iii
526
M-4-19-i
527
M-4-19-ii
528
M-4-19-iii
529
M-4-20-i
530
M-4-20-ii
531
M-4-20-iii
532
M-4-21-i
533
M-4-21-ii
534
M-4-21-iii
535
N-1-01-i
4.147.845
4.272.281
4.355.237
4.438.194
536
N-1-01-ii
5.609.867
5.778.163
5.890.360
6.002.558
537
N-1-01-iii
11.894.587
12.251.424
12.489.316
12.727.208
6.266.647
6.454.646
6.579.979
6.705.312
8.475.498
8.729.763
8.899.273
9.068.783
538
N-1-11-i
539
N-1-11-ii

RINGAN
SEDANG
- 782 No
Kode
INA-CBG
540
N-1-11-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
16.520.526
17.016.142
17.346.553
17.676.963
3.097.599
3.190.527
3.252.479
3.314.431
7.891.902
8.128.659
8.286.497
8.444.335
14.383.482
14.814.987
15.102.656
15.390.326
541
N-1-12-i
542
N-1-12-ii
543
N-1-12-iii
544
N-1-20-i
4.592.880
4.730.667
4.822.525
4.914.382
545
N-1-20-ii
9.106.049
9.379.231
9.561.352
9.743.473
546
N-1-20-iii
10.416.495
10.728.990
10.937.320
11.145.649
5.464.042
5.627.963
5.737.244
5.846.525
8.303.293
8.552.392
8.718.458
8.884.524
9.558.460
9.845.214
10.036.383
10.227.552
4.923.637
5.071.346
5.169.818
5.268.291
6.674.165
6.874.390
7.007.873
7.141.357
7.762.247
7.995.114
8.150.359
8.305.604
1.916.232
1.973.719
2.012.044
2.050.369
2.809.988
2.894.288
2.950.487
3.006.687
5.616.269
5.784.757
5.897.082
6.009.407

URIN BAWAH RINGAN
URIN BAWAH SEDANG
URIN BAWAH BERAT
RINGAN
SEDANG
BERAT
GINJAL RINGAN
GINJAL SEDANG
GINJAL BERAT
547
N-1-30-i
548
N-1-30-ii
549
N-1-30-iii
550
N-1-40-i
551
N-1-40-ii
552
N-1-40-iii
553
N-4-10-i
554
N-4-10-ii
555
N-4-10-iii
556
N-4-11-i
1.607.060
1.655.271
1.687.413
1.719.554
557
N-4-11-ii
2.715.892
2.797.369
2.851.687
2.906.004
558
N-4-11-iii
3.107.867
3.201.103
3.263.260
3.325.418
559
N-4-12-i
1.553.952
1.600.571
1.631.650
1.662.729
560
N-4-12-ii
2.299.479
2.368.463
2.414.453
2.460.442
561
N-4-12-iii
3.817.891
3.932.427
4.008.785
4.085.143
562
N-4-13-i
BATU URIN RINGAN
2.214.883
2.281.330
2.325.627
2.369.925
563
N-4-13-ii
BATU URIN SEDANG
2.670.316
2.750.426
2.803.832
2.857.238
564
N-4-13-iii
BATU URIN BERAT
6.576.256
6.773.544
6.905.069
7.036.594
1.327.850
1.367.685
1.394.242
1.420.799
2.044.722
2.106.064
2.146.958
2.187.852
3.315.887
3.415.364
3.481.681
3.547.999
2.157.377
2.222.098
2.265.246
2.308.393
565
N-4-14-i
566
N-4-14-ii
567
N-4-14-iii
568
N-4-15-i

(RINGAN)
(SEDANG)
(BERAT)
SALURAN URIN RINGAN
- 783 No
Kode
INA-CBG
569
N-4-15-ii
570
N-4-15-iii
571
N-4-16-i
572
N-4-16-ii
573
N-4-16-iii
574
O-6-10-i
575
O-6-10-ii
576
O-6-10-iii
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
584
585
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.960.592
3.049.410
3.108.622
3.167.834
3.378.570
3.479.927
3.547.499
3.615.070
2.166.693
2.231.694
2.275.028
2.318.361
3.065.972
3.157.951
3.219.270
3.280.590
6.447.283
6.640.701
6.769.647
6.898.592
2.694.965
2.775.814
2.829.713
2.883.613
2.991.822
3.081.577
3.141.413
3.201.250
3.686.938
3.797.546
3.871.285
3.945.024
1.701.367
1.752.408
1.786.436
1.820.463
2.772.026
2.855.187
2.910.628
2.966.068
4.697.724
4.838.656
4.932.610
5.026.565
1.881.578
1.938.026
1.975.657
2.013.289
2.259.771
2.327.564
2.372.760
2.417.955
2.839.078
2.924.251
2.981.032
3.037.814
1.391.313
1.433.052
1.460.879
1.488.705
O-6-13-ii
1.557.653
1.604.383
1.635.536
1.666.689
O-6-13-iii
1.937.148
1.995.263
2.034.006
2.072.749
38.517.557
39.673.083
40.443.434
41.213.786
47.659.451
49.089.235
50.042.424
50.995.613
55.938.835
57.617.001
58.735.777
59.854.554
51.106.576
52.639.773
53.661.905
54.684.036
58.624.503
60.383.238
61.555.729
62.728.219
66.982.687
68.992.167
70.331.821
71.671.475
2.581.332
2.658.772
2.710.399
2.762.025
3.613.865
3.722.281
3.794.558
3.866.836
5.692.657
5.863.437
5.977.290
6.091.143
25.246.210
26.003.596
26.508.520
27.013.444
32.764.137
33.747.061
34.402.344
35.057.626
46.975.525
48.384.791
49.324.301
50.263.812
586
P-8-01-i
587
P-8-01-ii
588
P-8-01-iii
589
P-8-02-i
590
P-8-02-ii
591
P-8-02-iii
592
P-8-03-i
593
P-8-03-ii
594
P-8-03-iii
595
P-8-04-i
596
P-8-04-ii
597
P-8-04-iii

SALURAN URIN SEDANG
SALURAN URIN BERAT
RINGAN
SEDANG
BERAT
&KURET RINGAN
KURET SEDANG
KURET BERAT

- 784 No
Kode
INA-CBG
598
P-8-05-i
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii
603
P-8-06-iii
604
P-8-07-i
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
614
P-8-11-ii
615
P-8-11-iii
616
P-8-12-i
617
P-8-12-ii
618
P-8-12-iii
619
P-8-13-i
620
P-8-13-ii
621
P-8-13-iii
622
P-8-14-i
623
P-8-14-ii
624
P-8-14-iii
625
P-8-15-i
Deskripsi (INA-CBG)
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
RINGAN
SEDANG
BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
ASPIRASI RINGAN
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
13.728.070
14.139.912
14.414.474
14.689.035
19.457.689
20.041.419
20.430.573
20.819.727
28.668.292
29.528.341
30.101.707
30.675.073
2.065.066
2.127.018
2.168.319
2.209.620
5.690.578
5.861.296
5.975.107
6.088.919
10.585.125
10.902.679
11.114.381
11.326.084
3.648.227
3.757.674
3.830.638
3.903.603
10.132.408
10.436.380
10.639.028
10.841.676
13.422.928
13.825.615
14.094.074
14.362.533
2.868.045
2.954.086
3.011.447
3.068.808
4.071.593
4.193.741
4.275.173
4.356.605
5.747.839
5.920.275
6.035.231
6.150.188
1.779.332
1.832.712
1.868.298
1.903.885
2.577.621
2.654.950
2.706.502
2.758.054
5.060.630
5.212.449
5.313.661
5.414.874
2.155.335
2.219.995
2.263.102
2.306.208
10.669.036
10.989.107
11.202.488
11.415.869
10.892.554
11.219.331
11.437.182
11.655.033
2.364.226
2.435.152
2.482.437
2.529.721
3.675.960
3.786.239
3.859.758
3.933.277
4.336.856
4.466.961
4.553.698
4.640.435
1.221.959
1.258.618
1.283.057
1.307.496
2.261.226
2.329.063
2.374.287
2.419.512
3.381.905
3.483.362
3.551.000
3.618.639
2.232.647
2.299.626
2.344.279
2.388.932
4.558.432
4.695.185
4.786.354
4.877.523
5.000.583
5.150.601
5.250.613
5.350.624
1.679.020
1.729.390
1.762.971
1.796.551
- 785 No
Kode
INA-CBG
626
P-8-15-ii
627
P-8-15-iii
628
P-8-16-i
629
P-8-16-ii
630
P-8-16-iii
631
P-8-17-i
632
P-8-17-ii
633
P-8-17-iii
634
S-4-10-i
635
S-4-10-ii
636
S-4-10-iii
637
S-4-11-i
638
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.355.919
3.456.597
3.523.715
3.590.834
3.942.047
4.060.308
4.139.149
4.217.990
1.519.910
1.565.507
1.595.905
1.626.303
2.156.057
2.220.739
2.263.860
2.306.981
2.798.668
2.882.628
2.938.601
2.994.575
1.001.316
1.031.355
1.051.382
1.071.408
3.332.082
3.432.045
3.498.686
3.565.328
6.725.596
6.927.363
7.061.875
7.196.387
1.532.986
1.578.975
1.609.635
1.640.295
1.916.232
1.973.719
2.012.044
2.050.369
2.490.773
2.565.496
2.615.312
2.665.127
958.116
986.860
1.006.022
1.025.184
S-4-11-ii
1.532.986
1.578.975
1.609.635
1.640.295
639
S-4-11-iii
2.359.227
2.430.004
2.477.189
2.524.373
640
S-4-12-i
1.149.739
1.184.232
1.207.226
1.230.221
641
S-4-12-ii
1.532.986
1.578.975
1.609.635
1.640.295
642
S-4-12-iii
2.994.043
3.083.864
3.143.745
3.203.626
1.532.986
1.578.975
1.609.635
1.640.295
2.709.975
2.791.275
2.845.474
2.899.674
5.517.854
5.683.390
5.793.747
5.904.104
934.020
962.041
980.721
999.402
1.984.172
2.043.697
2.083.381
2.123.064
3.762.697
3.875.578
3.950.832
4.026.086
706.408
727.600
741.728
755.857
1.333.233
1.373.230
1.399.894
1.426.559
1.726.846
1.778.651
1.813.188
1.847.725

ASPIRASI SEDANG
ASPIRASI BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT

PASIEN RINGAN
PASIEN SEDANG
PASIEN BERAT
643
S-4-13-i
644
S-4-13-ii
645
S-4-13-iii
646
S-4-14-i
647
S-4-14-ii
648
S-4-14-iii
649
S-4-15-i
650
S-4-15-ii
651
S-4-15-iii
652
S-4-16-i
LUKA BAKAR RINGAN
2.682.725
2.763.207
2.816.862
2.870.516
653
S-4-16-ii
LUKA BAKAR SEDANG
4.149.328
4.273.808
4.356.794
4.439.781
654
S-4-16-iii
LUKA BAKAR BERAT
7.409.269
7.631.547
7.779.733
7.927.918
1.566.567
1.613.564
1.644.895
1.676.227
1.916.232
1.973.719
2.012.044
2.050.369
3.124.795
3.218.539
3.281.035
3.343.531
655
S-4-17-i
656
S-4-17-ii
657
S-4-17-iii

- 786 No
Kode
INA-CBG
658
T-1-10-i
659
T-1-10-ii
660
T-1-10-iii
661
T-4-10-i
662
T-4-10-ii
663
T-4-10-iii
664
T-4-11-i
665
T-4-11-ii
666
T-4-11-iii
667
T-4-12-i
668
T-4-12-ii
669
T-4-12-iii
670
U-1-10-i
671
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.617.130
1.665.643
1.697.986
1.730.329
2.171.695
2.236.846
2.280.280
2.323.714
3.951.022
4.069.552
4.148.573
4.227.593
645.930
665.308
678.226
691.145
1.230.999
1.267.929
1.292.549
1.317.169
1.789.538
1.843.224
1.879.015
1.914.806
699.557
720.544
734.535
748.526
1.100.903
1.133.931
1.155.949
1.177.967
1.773.231
1.826.428
1.861.893
1.897.357
1.341.363
1.381.604
1.408.431
1.435.258
2.027.396
2.088.218
2.128.766
2.169.314
3.153.899
3.248.516
3.311.594
3.374.672
1.427.758
1.470.590
1.499.146
1.527.701
U-1-10-ii
2.913.427
3.000.830
3.059.099
3.117.367
672
U-1-10-iii
12.580.768
12.958.191
13.209.806
13.461.421
673
U-1-11-i
6.195.197
6.381.053
6.504.957
6.628.861
674
U-1-11-ii
8.260.263
8.508.071
8.673.276
8.838.482
675
U-1-11-iii
15.198.224
15.654.171
15.958.135
16.262.100
676
U-1-12-i
4.146.119
4.270.503
4.353.425
4.436.347
677
U-1-12-ii
9.292.796
9.571.580
9.757.436
9.943.292
678
U-1-12-iii
12.066.872
12.428.878
12.670.215
12.911.553
679
U-1-13-i
4.130.132
4.254.036
4.336.638
4.419.241
680
U-1-13-ii
5.103.218
5.256.314
5.358.379
5.460.443
681
U-1-13-iii
8.985.619
9.255.187
9.434.900
9.614.612
2.495.672
2.570.542
2.620.456
2.670.369
3.062.691
3.154.572
3.215.826
3.277.080
3.629.375
3.738.257
3.810.844
3.883.432

DOKTER RINGAN
DOKTER SEDANG
DOKTER BERAT

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)

682
U-1-14-i
683
U-1-14-ii
684
U-1-14-iii
685
U-1-15-i
1.465.803
1.509.777
1.539.093
1.568.410
686
U-1-15-ii
2.082.804
2.145.288
2.186.944
2.228.600
687
U-1-15-iii
4.104.249
4.227.377
4.309.462
4.391.547
U-1-20-i

3.791.395
3.905.137
3.980.964
4.056.792
688
- 787 No
Kode
INA-CBG
689
U-1-20-ii
690
U-1-20-iii
691
U-1-30-i
692
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
6.748.683
6.951.143
7.086.117
7.221.090
15.202.952
15.659.040
15.963.099
16.267.158
3.252.355
3.349.926
3.414.973
3.480.020
U-1-30-ii
4.390.680
4.522.400
4.610.214
4.698.027
693
U-1-30-iii
8.260.263
8.508.071
8.673.276
8.838.482
694
U-4-10-i
3.027.400
3.118.222
3.178.770
3.239.318
695
U-4-10-ii
7.589.055
7.816.727
7.968.508
8.120.289
696
U-4-10-iii
11.070.779
11.402.902
11.624.318
11.845.733
697
U-4-11-i
1.532.986
1.578.975
1.609.635
1.640.295
698
U-4-11-ii
2.299.479
2.368.463
2.414.453
2.460.442
699
U-4-11-iii
3.482.708
3.587.189
3.656.843
3.726.497
700
U-4-12-i
1.532.986
1.578.975
1.609.635
1.640.295
701
U-4-12-ii
1.957.121
2.015.834
2.054.977
2.094.119
702
U-4-12-iii
3.111.733
3.205.085
3.267.319
3.329.554
703
U-4-13-i
1.532.986
1.578.975
1.609.635
1.640.295
704
U-4-13-ii
1.750.866
1.803.392
1.838.409
1.873.427
705
U-4-13-iii
2.177.102
2.242.415
2.285.957
2.329.499
706
U-4-14-i
1.916.232
1.973.719
2.012.044
2.050.369
707
U-4-14-ii
2.299.479
2.368.463
2.414.453
2.460.442
708
U-4-14-iii
3.852.026
3.967.587
4.044.627
4.121.668
709
U-4-15-i
1.532.986
1.578.975
1.609.635
1.640.295
710
U-4-15-ii
1.916.232
1.973.719
2.012.044
2.050.369
711
U-4-15-iii
2.683.245
2.763.743
2.817.408
2.871.073
712
V-1-10-i
4.481.426
4.615.869
4.705.497
4.795.126
713
V-1-10-ii
5.162.664
5.317.544
5.420.798
5.524.051
714
V-1-10-iii
9.809.062
10.103.334
10.299.516
10.495.697
715
V-1-11-i
5.162.664
5.317.544
5.420.798
5.524.051
716
V-1-11-ii
5.761.620
5.934.469
6.049.701
6.164.934
717
V-1-11-iii
8.532.077
8.788.040
8.958.681
9.129.323
3.053.508
3.145.113
3.206.183
3.267.253
11.448.951
11.792.420
12.021.399
12.250.378
12.875.847
13.262.122
13.519.639
13.777.156
4.628.128
4.766.971
4.859.534
4.952.097
718
V-1-12-i
719
V-1-12-ii
720
V-1-12-iii
721
V-1-13-i


DAN TELINGA RINGAN
DAN TELINGA SEDANG
DAN TELINGA BERAT


KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

- 788 No
Kode
INA-CBG
722
V-1-13-ii
723
V-1-13-iii
724
V-1-14-i
725
V-1-14-ii
726
V-1-14-iii
727
V-1-15-i
728
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
8.794.771
9.058.614
9.234.509
9.410.405
12.390.395
12.762.107
13.009.914
13.257.722
5.579.262
5.746.639
5.858.225
5.969.810
8.114.558
8.357.995
8.520.286
8.682.577
11.030.561
11.361.478
11.582.089
11.802.700
2.630.311
2.709.221
2.761.827
2.814.433
V-1-15-ii
4.834.006
4.979.026
5.075.706
5.172.387
729
V-1-15-iii
8.042.762
8.284.045
8.444.900
8.605.756
730
V-4-10-i
4.235.465
4.362.529
4.447.238
4.531.948
731
V-4-10-ii
5.470.609
5.634.727
5.744.140
5.853.552
732
V-4-10-iii
10.455.294
10.768.953
10.978.059
11.187.165
733
V-4-11-i
2.153.893
2.218.509
2.261.587
2.304.665
734
V-4-11-ii
3.147.181
3.241.597
3.304.540
3.367.484
735
V-4-11-iii
5.192.641
5.348.420
5.452.273
5.556.125
736
W-1-01-i
6.333.499
6.523.504
6.650.174
6.776.844
737
W-1-01-ii
7.628.399
7.857.251
8.009.819
8.162.387
738
W-1-01-iii
16.849.618
17.355.107
17.692.099
18.029.092
739
W-1-10-i
1.763.872
1.816.788
1.852.065
1.887.343
740
W-1-10-ii
3.291.674
3.390.425
3.456.258
3.522.092
741
W-1-10-iii
5.384.135
5.545.659
5.653.342
5.761.024
742
W-1-11-i
1.832.076
1.887.039
1.923.680
1.960.322
743
W-1-11-ii
3.533.391
3.639.393
3.710.061
3.780.728
744
W-1-11-iii
6.195.197
6.381.053
6.504.957
6.628.861
745
W-1-12-i
1.664.717
1.714.658
1.747.952
1.781.247
746
W-1-12-ii
1.892.751
1.949.533
1.987.388
2.025.244
747
W-1-12-iii
2.907.504
2.994.729
3.052.879
3.111.029
748
W-1-13-i
1.809.285
1.863.563
1.899.749
1.935.934
749
W-1-13-ii
1.964.362
2.023.292
2.062.580
2.101.867
750
W-1-13-iii
2.638.500
2.717.655
2.770.425
2.823.195
751
W-1-20-i
5.398.768
5.560.731
5.668.706
5.776.681
752
W-1-20-ii
7.594.177
7.822.002
7.973.885
8.125.769
753
W-1-20-iii
9.292.796
9.571.580
9.757.436
9.943.292

NON KOMPLEK (BERAT)

RINGAN
SEDANG
BERAT

SERVIK RINGAN
SERVIK SEDANG
SERVIK BERAT
ENDOSKOP RINGAN
ENDOSKOP SEDANG
ENDOSKOP BERAT
- 789 No
Kode
INA-CBG
754
W-1-30-i
755
W-1-30-ii
756
W-1-30-iii
757
W-4-10-i
758
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.947.186
3.035.601
3.094.545
3.153.489
4.700.914
4.841.941
4.935.959
5.029.978
12.500.886
12.875.913
13.125.931
13.375.948
2.197.862
2.263.798
2.307.755
2.351.713
W-4-10-ii
2.970.657
3.059.777
3.119.190
3.178.603
759
W-4-10-iii
6.131.944
6.315.902
6.438.541
6.561.180
760
W-4-11-i
1.916.232
1.973.719
2.012.044
2.050.369
761
W-4-11-ii
3.065.972
3.157.951
3.219.270
3.280.590
762
W-4-11-iii
3.726.064
3.837.846
3.912.368
3.986.889
763
W-4-12-i
1.532.986
1.578.975
1.609.635
1.640.295
764
W-4-12-ii
2.133.181
2.197.177
2.239.840
2.282.504
765
W-4-12-iii
2.573.589
2.650.796
2.702.268
2.753.740
766
W-4-13-i
ABORTUS RINGAN
840.708
865.929
882.743
899.557
767
W-4-13-ii
ABORTUS SEDANG
1.149.739
1.184.232
1.207.226
1.230.221
768
W-4-13-iii
ABORTUS BERAT
1.532.986
1.578.975
1.609.635
1.640.295
769
W-4-14-i
1.149.739
1.184.232
1.207.226
1.230.221
770
W-4-14-ii
1.532.986
1.578.975
1.609.635
1.640.295
771
W-4-14-iii
1.860.721
1.916.542
1.953.757
1.990.971
772
W-4-15-i
1.049.957
1.081.456
1.102.455
1.123.454
773
W-4-15-ii
1.167.752
1.202.785
1.226.140
1.249.495
774
W-4-15-iii
1.563.359
1.610.260
1.641.527
1.672.794
775
W-4-16-i
1.149.739
1.184.232
1.207.226
1.230.221
776
W-4-16-ii
1.668.913
1.718.981
1.752.359
1.785.737
777
W-4-16-iii
2.126.994
2.190.804
2.233.344
2.275.883
778
W-4-17-i
1.028.391
1.059.243
1.079.811
1.100.378
779
W-4-17-ii
1.532.986
1.578.975
1.609.635
1.640.295
780
W-4-17-iii
2.900.104
2.987.108
3.045.110
3.103.112
781
Z-4-10-i
REHABILITASI RINGAN
2.630.422
2.709.335
2.761.943
2.814.552
782
Z-4-10-ii
REHABILITASI SEDANG
3.491.506
3.596.251
3.666.081
3.735.911
783
Z-4-10-iii
REHABILITASI BERAT
4.960.017
5.108.818
5.208.018
5.307.218
784
Z-4-11-i
2.514.500
2.589.935
2.640.225
2.690.515
785
Z-4-11-ii
3.026.902
3.117.709
3.178.247
3.238.785
786
Z-4-11-iii
4.732.145
4.874.110
4.968.752
5.063.395
787
Z-4-12-i

1.149.739
1.184.232
1.207.226
1.230.221

RINGAN
SEDANG
BERAT

- 790 No
Kode
INA-CBG
788
Z-4-12-ii
789
Z-4-12-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.565.409
2.642.372
2.693.680
2.744.988
3.260.229
3.358.036
3.423.241
3.488.445
- 791 b. RawatJalan
No
Kode
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
775.006
798.256
813.756
829.256
1.005.304
1.035.463
1.055.569
1.075.675
1.869.494
1.925.579
1.962.969
2.000.359
1.544.956
1.591.304
1.622.204
1.653.103
1.290.677
1.329.398
1.355.211
1.381.025
452.517
466.093
475.143
484.193
1.009.054
1.039.326
1.059.507
1.079.688

207.327
213.547
217.694
221.840
C-3-10-0
565.560
582.527
593.838
605.149
10
C-3-11-0

KANDUNG KEMIH
894.454
921.288
939.177
957.066
11
C-3-12-0
202.771
208.854
212.909
216.965
196.904
202.812
206.750
210.688
1.676.251
1.726.538
1.760.063
1.793.588
1.536.351
1.582.441
1.613.168
1.643.895

LAPAROSKOPI
PANKREAS
LAPAROSKOPI
EMPEDU

OVARIUM
GASTROINTESTINAL
GINJAL ATAU PROSTAT
12
C-3-13-0
13
C-3-14-0
14
C-3-15-0
15
C-3-16-0
348.407
358.860
365.828
372.796
16
C-3-17-0

LEHER
231.123
238.057
242.679
247.302
17
C-3-18-0
102.470
105.544
107.594
109.643
18
C-3-19-0

MYELOMA ATAU TESTIS
144.913
149.261
152.159
155.057
19
C-3-20-0
2.885.957
2.972.536
3.030.255
3.087.974
20
C-3-21-0
165.372
170.333
173.641
176.948
21
C-3-22-0
726.072
747.854
762.376
776.897
22
C-3-23-0
117.608
121.136
123.488
125.840
23
D-2-10-0

TULANG
996.390
1.026.282
1.046.209
1.066.137
24
D-2-11-0
PROSEDUR LIMPA
1.247.650
1.285.080
1.310.033
1.334.986
25
D-2-21-0
1.046.425
1.077.818
1.098.747
1.119.675
26
D-2-22-0
229.659
236.549
241.142
245.735
27
D-3-10-0
166.348
171.338
174.665
177.992
28
D-3-11-0
431.886
444.843
453.481
462.118
29
E-2-10-0
256.192
263.877
269.001
274.125
30
E-2-21-0
185.730
191.302
195.017
198.731
31
E-2-22-0
185.730
191.302
195.017
198.731

TYMUS
TYMUS
TULANG
PEMBENTUK DARAH
PARATIROID
THYROGLOSSAL
- 792 No
Kode
INA-CBG
32
E-3-10-0
33
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

ENDOKRIN
215.992
222.472
226.792
231.112
F-3-10-0
TERAPI SHOCK
301.302
310.341
316.367
322.393
34
F-5-10-0
369.193
380.268
387.652
395.036
35
F-5-11-0
TERAPI KELOMPOK
243.449
250.752
255.621
260.490
36
F-5-12-0
311.534
320.880
327.110
333.341
37
F-5-13-0
263.848
271.764
277.041
282.318
38
F-5-14-0
177.007
182.317
185.857
189.397
39
F-5-15-0
166.055
171.037
174.358
177.679
40
F-5-16-0
172.963
178.151
181.611
185.070
41
G-2-10-0
145.648
150.017
152.930
155.843
42
G-2-11-0
1.262.536
1.300.412
1.325.663
1.350.914
43
G-2-12-0

EKSTRAKRANIAL
1.829.726
1.884.618
1.921.212
1.957.807
44
G-2-13-0
448.873
462.339
471.316
480.294
45
G-2-21-0
818.668
843.228
859.601
875.975
46
G-2-22-0
743.011
765.301
780.161
795.022
47
G-2-31-0
1.226.033
1.262.814
1.287.334
1.311.855
48
G-2-32-0
628.463
647.317
659.886
672.456
49
G-3-10-0
249.441
256.924
261.913
266.902
50
G-3-11-0
332.208
342.174
348.818
355.462
51
G-3-12-0
544.328
560.658
571.544
582.431
52
G-3-13-0
544.390
560.722
571.610
582.497
53
H-2-21-0
714.431
735.864
750.153
764.441
54
H-2-22-0
185.730
191.302
195.017
198.731
55
H-2-23-0
185.730
191.302
195.017
198.731
56
H-2-31-0
1.183.396
1.218.898
1.242.565
1.266.233
57
H-2-32-0
123.164
126.859
129.322
131.785
58
H-2-33-0
185.730
191.302
195.017
198.731
59
H-2-34-0
530.900
546.827
557.445
568.063
60
H-2-35-0
174.944
180.192
183.691
187.190
61
H-2-36-0
944.305
972.634
991.520
1.010.406
62
H-2-37-0

1.005.254
1.035.412
1.055.517
1.075.622
63
H-3-10-0
349.755
360.248
367.243
374.238
64
H-3-11-0
183.932
189.450
193.129
196.808

AKUT
MENTAL
PROSEDUR KRANIOTOMI

MATA
MATA
MATA
MATA
MATA
- 793 No
Kode
INA-CBG
65
H-3-12-0
66
H-3-13-0
67
I-2-11-0
68
I-2-12-0
69
I-2-13-0
70
I-2-14-0
71
I-2-15-0
Deskripsi (INA-CBG)
MATA
TORASIK
ABDOMEN
PENGGANTIAN ALAT
DARAH VENA
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
192.035
197.796
201.636
205.477
186.454
192.048
195.777
199.506
2.150.214
2.214.720
2.257.725
2.300.729
1.511.835
1.557.190
1.587.427
1.617.663
1.921.451
1.979.095
2.017.524
2.055.953
3.400.560
3.502.576
3.570.588
3.638.599
204.503
210.638
214.728
218.818
2.147.884
2.212.320
2.255.278
2.298.235
708.096
729.338
743.500
757.662
72
I-2-16-0
73
I-2-17-0
74
I-2-21-0
1.657.861
1.707.597
1.740.754
1.773.911
75
I-2-22-0
1.561.166
1.608.001
1.639.225
1.670.448
76
I-2-23-0
319.488
329.073
335.462
341.852
77
I-2-31-0
2.484.766
2.559.309
2.609.004
2.658.700
78
I-2-32-0
3.249.197
3.346.672
3.411.656
3.476.640
79
I-2-41-0
2.178.626
2.243.985
2.287.558
2.331.130
80
I-2-42-0

LAIN
2.533.013
2.609.004
2.659.664
2.710.324
81
I-3-10-0
PROSEDUR RESUSITASI
321.544
331.190
337.621
344.052
82
I-3-11-0
169.710
174.801
178.195
181.590
83
I-3-12-0
986.290
1.015.879
1.035.605
1.055.331
84
I-3-13-0
323.936
333.654
340.133
346.611
85
I-3-14-0
207.632
213.861
218.013
222.166
183.932
189.450
193.129
196.808
1.138.791
1.172.955
1.195.730
1.218.506
183.573
189.080
192.752
196.423
925.093
952.845
971.347
989.849
1.199.928
1.235.926
1.259.924
1.283.923

PACU JANTUNG

KARDIOVASKULAR
PERNAFASAN
PENDEK
86
I-3-15-0
87
J-2-10-0
88
J-2-21-0
89
J-2-22-0
90
J-2-31-0
PROSEDUR
91
J-2-32-0
892.945
919.734
937.593
955.452
92
J-3-10-0
185.730
191.302
195.017
198.731
93
J-3-11-0

PADA DADA
524.840
540.586
551.082
561.579
94
J-3-12-0
202.771
208.854
212.909
216.965
95
J-3-13-0
298.428
307.381
313.350
319.318
96
J-3-14-0
316.814
326.318
332.655
338.991
- 794 No
Kode
INA-CBG
97
J-3-15-0
98
J-3-16-0
99
J-3-17-0
100
K-2-10-0
101
K-2-11-0
102
K-2-12-0

103
K-2-13-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
277.821
286.155
291.712
297.268
316.814
326.318
332.655
338.991
185.730
191.302
195.017
198.731
534.595
550.633
561.325
572.017
1.141.578
1.175.826
1.198.657
1.221.489
876.309
902.598
920.124
937.650
1.426.240
1.469.027
1.497.552
1.526.077
185.730
191.302
195.017
198.731
185.730
191.302
195.017
198.731
2.387.075
2.458.687
2.506.429
2.554.170
802.652
826.732
842.785
858.838
185.730
191.302
195.017
198.731

PERNAFASAN
KECIL

FEMORALIS
USUS BESAR
ATAS
ATAS
104
K-2-14-0
105
K-2-21-0
106
K-2-22-0
107
K-2-31-0
108
K-2-32-0
109
K-2-41-0
884.138
910.662
928.345
946.027
110
K-2-42-0

252.609
260.187
265.240
270.292
111
K-2-51-0
585.883
603.460
615.177
626.895
112
K-2-52-0
319.488
329.073
335.462
341.852
113
K-2-53-0
185.730
191.302
195.017
198.731
114
K-3-10-0

GASTROINTESTINAL
353.432
364.035
371.104
378.172
115
K-3-11-0
212.482
218.856
223.106
227.355
116
K-3-12-0
215.483
221.948
226.257
230.567
117
K-3-13-0
185.730
191.302
195.017
198.731
497.761
512.694
522.649
532.604
240.376
247.587
252.394
257.202
318.513
328.068
334.439
340.809
1.095.060
1.127.911
1.149.813
1.171.714
701.925
722.983
737.022
751.060
316.814
326.318
332.655
338.991
319.488
329.073
335.462
341.852

GASTROINTESTINAL
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
118
K-3-14-0
119
K-3-15-0
120
K-3-16-0
121
L-2-21-0
122
L-2-22-0
123
L-2-31-0
124
L-2-32-0
125
L-2-41-0
956.669
985.369
1.004.502
1.023.636
126
L-2-42-0

214.565
221.002
225.294
229.585
127
L-2-51-0
1.432.283
1.475.252
1.503.897
1.532.543
L-2-52-0

1.095.744
1.128.616
1.150.531
1.172.446
128
- 795 No
Kode
INA-CBG
129
L-2-53-0
130
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

185.730
191.302
195.017
198.731
L-3-10-0
252.609
260.187
265.240
270.292
131
L-3-11-0
245.301
252.660
257.566
262.472
132
L-3-12-0
186.820
192.425
196.161
199.897
133
M-2-10-0
1.465.330
1.509.290
1.538.597
1.567.903
134
M-2-21-0
1.312.305
1.351.674
1.377.920
1.404.166
135
M-2-22-0
319.488
329.073
335.462
341.852
136
M-2-31-0
PROSEDUR BUNION
797.093
821.006
836.948
852.890
137
M-2-32-0
252.609
260.187
265.240
270.292
138
M-2-41-0

TULANG
252.609
260.187
265.240
270.292
139
M-2-42-0
87.056
89.668
91.409
93.150
140
M-2-51-0
185.730
191.302
195.017
198.731
141
M-2-52-0
185.730
191.302
195.017
198.731
142
M-2-61-0
PROSEDUR ARTROSKOPI
910.361
937.672
955.879
974.086
143
M-2-62-0
185.730
191.302
195.017
198.731
915.285
942.744
961.050
979.355
1.248.260
1.285.708
1.310.673
1.335.639
185.730
191.302
195.017
198.731
921.544
949.191
967.621
986.052
889.329
916.009
933.796
951.583

DAN WAJAH
PAHA
PAHA

TULANG
WAJAH
WAJAH
BAWAH
BAWAH
144
M-2-63-0
145
M-2-64-0
146
M-2-65-0
147
M-2-71-0
148
M-2-72-0
149
M-2-81-0
1.326.180
1.365.965
1.392.489
1.419.012
150
M-2-82-0
963.384
992.286
1.011.554
1.030.821
151
M-2-83-0
185.730
191.302
195.017
198.731
152
M-2-84-0
185.730
191.302
195.017
198.731
153
M-3-10-0
530.110
546.013
556.615
567.217
154
M-3-11-0
293.914
302.731
308.609
314.487
155
M-3-12-0
664.663
684.603
697.896
711.189
156
M-3-13-0
216.698
223.199
227.533
231.867
157
M-3-14-0

TERTUTUP
370.374
381.485
388.892
396.300
158
M-3-15-0
163.172
168.067
171.331
174.594
159
M-3-16-0

185.730
191.302
195.017
198.731
160
M-3-17-0
202.771
208.854
212.909
216.965
161
N-2-11-0
2.453.678
2.527.288
2.576.362
2.625.435

PERGELANGAN TANGAN
PERGELANGAN TANGAN
MUSKULOSKELETAL
SKELETAL
- 796 No
Kode
INA-CBG
162
N-2-12-0
163
N-2-21-0
164
N-2-22-0
165
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.419.428
1.462.011
1.490.400
1.518.788
1.411.946
1.454.305
1.482.544
1.510.783
319.488
329.073
335.462
341.852
N-2-23-0
319.488
329.073
335.462
341.852
166
N-2-24-0
1.032.478
1.063.452
1.084.102
1.104.751
167
N-2-31-0
869.179
895.254
912.638
930.022
168
N-2-32-0
319.488
329.073
335.462
341.852
169
N-2-41-0
319.488
329.073
335.462
341.852
170
N-2-42-0
540.315
556.525
567.331
578.138
171
N-3-10-0
319.488
329.073
335.462
341.852
172
N-3-11-0
370.172
381.278
388.681
396.085
173
N-3-12-0
286.049
294.630
300.351
306.072
174
N-3-13-0
319.488
329.073
335.462
341.852
175
N-3-14-0
274.902
283.149
288.647
294.145
176
N-3-15-0
704.918
726.066
740.164
754.262
177
O-7-10-0
117.691
121.222
123.575
125.929
178
O-7-11-0
648.155
667.600
680.563
693.526
179
O-7-12-0
236.015
243.096
247.816
252.536
180
O-7-13-0
131.167
135.102
137.725
140.348
181
P-9-10-0
174.944
180.192
183.691
187.190
182
P-9-11-0
174.944
180.192
183.691
187.190
183
P-9-12-0
174.944
180.192
183.691
187.190
184
P-9-13-0
174.944
180.192
183.691
187.190
185
P-9-14-0
174.944
180.192
183.691
187.190
186
P-9-15-0
111.513
114.858
117.088
119.319
187
P-9-16-0
174.944
180.192
183.691
187.190
188
P-9-17-0
174.191
179.417
182.901
186.385
189
Q-5-10-0
228.007
234.848
239.408
243.968
190
Q-5-11-0
170.885
176.012
179.430
182.847
191
Q-5-12-0
GIGI
150.614
155.132
158.144
161.157
192
Q-5-13-0
MEDICAL CHECK-UP
114.460
117.894
120.183
122.472
193
Q-5-14-0
125.943
129.722
132.240
134.759


DAN URETHRA
DAN URETHRA
TRANSURETHRA
TRANSURETHRA
SALURAN KEMIH
KEMIH
KEMIH
PROSEDUR DIALISIS
CAESAR
VAGINAL/JALAN LAHIR

ASPIRASI
- 797 No
Kode
INA-CBG
194
Q-5-15-0
195
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
86.611
89.209
90.942
92.674
Q-5-16-0
VAKSINASI
97.891
100.827
102.785
104.743
196
Q-5-17-0
PASANG INFUS
84.673
87.213
88.906
90.600
197
Q-5-18-0
159.381
164.162
167.350
170.537
198
Q-5-19-0
178.178
183.523
187.087
190.651
199
Q-5-20-0
ABORSI MENGANCAM
119.427
123.010
125.398
127.787
200
Q-5-21-0
ABORSI
117.800
121.334
123.690
126.046
201
Q-5-22-0
125.943
129.722
132.240
134.759
202
Q-5-23-0
154.188
158.813
161.897
164.981
203
Q-5-24-0
105.308
108.467
110.573
112.680
204
Q-5-25-0
164.226
169.153
172.437
175.722
205
Q-5-26-0
BRONKIAL AKUT
232.450
239.424
244.073
248.722
206
Q-5-27-0
165.423
170.386
173.694
177.003
207
Q-5-28-0
134.236
138.264
140.948
143.633
208
Q-5-29-0

JANTUNG LAIN-LAIN
380.046
391.447
399.048
406.649
209
Q-5-30-0
440.432
453.645
462.453
471.262
210
Q-5-31-0
FRAKTUR
157.128
161.842
164.985
168.127
211
Q-5-32-0
SALURAN KEMIH AKUT
181.990
187.450
191.090
194.729
212
Q-5-33-0
HEMATOLOGI AKUT
190.543
196.259
200.070
203.881
213
Q-5-34-0
INFEKSI VIRUS HIV
270.680
278.800
284.214
289.627
214
Q-5-35-0
INFEKSI AKUT
306.943
316.152
322.291
328.430
215
Q-5-36-0
357.456
368.179
375.328
382.477
216
Q-5-37-0

SHOCK
182.321
187.790
191.437
195.083
217
Q-5-38-0
PARU AKUT
243.130
250.424
255.287
260.150
218
Q-5-39-0
155.586
160.253
163.365
166.477
219
Q-5-40-0
152.654
157.234
160.287
163.340
220
Q-5-41-0
211.328
217.668
221.895
226.121
221
Q-5-42-0
165.690
170.660
173.974
177.288
222
Q-5-43-0
238.603
245.761
250.533
255.305
223
Q-5-44-0
194.733
200.575
204.470
208.364
224
T-2-10-0

TERAPI DETOKSIKASI
101.005
104.035
106.055
108.075
225
U-2-10-0
1.348.022
1.388.463
1.415.423
1.442.384
226
U-2-11-0

LEHER
1.602.274
1.650.343
1.682.388
1.714.434
227
U-2-12-0
176.292
181.581
185.107
188.632
- 798 No
Kode
INA-CBG
228
U-2-13-0
229
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
231.123
238.057
242.679
247.302
U-2-14-0
429.322
442.202
450.788
459.375
230
U-2-15-0
243.931
251.249
256.128
261.007
231
U-2-21-0
284.142
292.666
298.349
304.032
232
U-2-22-0
548.985
565.455
576.434
587.414
233
U-2-23-0
719.348
740.928
755.315
769.702
234
U-2-24-0
606.254
624.442
636.567
648.692
235
U-2-25-0
231.123
238.057
242.679
247.302
236
U-2-31-0
185.730
191.302
195.017
198.731
237
U-2-32-0
231.123
238.057
242.679
247.302
238
U-3-10-0
220.966
227.595
232.014
236.434
239
U-3-11-0
234.597
241.635
246.327
251.019
240
U-3-12-0
103.738
106.851
108.925
111.000
241
U-3-13-0
228.025
234.866
239.427
243.987
242
U-3-14-0
209.508
215.793
219.984
224.174
243
U-3-15-0
182.710
188.191
191.845
195.499
244
U-3-16-0
PROSEDUR PADA GIGI
206.063
212.245
216.367
220.488
245
V-2-10-0

PROSTAT
2.010.387
2.070.699
2.110.907
2.151.114
246
V-2-11-0
226.721
233.522
238.057
242.591
723.497
745.202
759.672
774.142
319.488
329.073
335.462
341.852
319.488
329.073
335.462
341.852

(RHINOPLASTY)

RONGGA HIDUNG
TENGGOROKAN
PROSEDUR PADA PENIS

SKROTUM
SKROTUM
TRANSURETHRAL
247
V-2-12-0
248
V-2-13-0
249
V-2-14-0
250
V-2-15-0
SIRKUMSISI/SUNAT
174.944
180.192
183.691
187.190
251
V-3-10-0
364.857
375.802
383.100
390.397
252
V-3-11-0
771.861
795.017
810.454
825.891
253
V-3-12-0
445.616
458.984
467.897
476.809
254
W-2-10-0
163.172
168.067
171.331
174.594
255
W-2-11-0
417.007
429.518
437.858
446.198
256
W-2-12-0
771.861
795.017
810.454
825.891
257
W-2-13-0
123.793
127.507
129.982
132.458
258
W-2-21-0
1.551.647
1.598.196
1.629.229
1.660.262
259
W-2-22-0
163.172
168.067
171.331
174.594

PROSEDUR ABORSI
RAHIM & LEHER RAHIM
TERHALANG/TERGANGGU
TERHALANG/TERGANGGU
PANGGUL TERBUKA
PANGGUL TERBUKA
- 799 No
Kode
INA-CBG
260
W-2-23-0
Deskripsi (INA-CBG)
JALAN LAHIR
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
544.514
560.849
571.739
582.630
1.787.473
1.841.097
1.876.846
1.912.596
1.253.636
1.291.245
1.316.317
1.341.390
261
W-2-31-0
262
W-2-32-0
263
W-2-33-0
532.812
548.796
559.452
570.109
264
W-2-34-0
181.219
186.655
190.280
193.904
265
W-3-10-0
440.431
453.644
462.453
471.262
266
W-3-11-0
352.068
362.630
369.672
376.713
267
W-3-12-0
163.172
168.067
171.331
174.594
268
Z-3-10-0
1.847.327
1.902.747
1.939.693
1.976.640
269
Z-3-11-0

EMPEDU
1.411.946
1.454.305
1.482.544
1.510.783
270
Z-3-12-0
235.761
242.834
247.549
252.264
271
Z-3-13-0

LAIN-LAIN
1.438.678
1.481.838
1.510.611
1.539.385
272
Z-3-14-0
DIAGNOSTIK TIDUR
284.471
293.005
298.695
304.384
273
Z-3-15-0
185.730
191.302
195.017
198.731
274
Z-3-16-0

(MRI)
596.137
614.022
625.944
637.867
275
Z-3-17-0
PENGOBATAN NUKLIR
250.271
257.780
262.785
267.790
276
Z-3-18-0
CT-SCAN KEPALA
241.132
248.366
253.188
258.011
277
Z-3-19-0
CT SCAN LAIN-LAIN
250.971
258.500
263.520
268.539
278
Z-3-20-0
170.692
175.812
179.226
182.640
279
Z-3-21-0
163.172
168.067
171.331
174.594
280
Z-3-22-0
183.962
189.481
193.160
196.839
281
Z-3-23-0
191.612
197.361
201.193
205.025
282
Z-3-24-0
376.480
387.775
395.304
402.834
283
Z-3-25-0
167.684
172.714
176.068
179.422
284
Z-3-26-0
189.516
195.201
198.992
202.782
285
Z-3-27-0
PERAWATAN LUKA
180.936
186.364
189.983
193.602
286
Z-3-28-0
IMAGING PAYUDARA
185.730
191.302
195.017
198.731
287
Z-3-29-0
IMAGING LAIN-LAIN
535.308
551.367
562.073
572.779
288
Z-3-30-0
FOTOTERAPI
90.340
93.050
94.857
96.664
- 800 5. RUMAH SAKIT PARUKELAS C

a. RawatInap
No
Kode
INA-CBG
A-4-10-i
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
SEPTIKEMIA RINGAN
2.174.376
2.239.607
2.283.095
2.326.582
A-4-10-ii
SEPTIKEMIA SEDANG
2.489.076
2.563.749
2.613.530
2.663.312
A-4-10-iii
SEPTIKEMIA BERAT
3.902.402
4.019.474
4.097.522
4.175.570
A-4-11-i
3.907.861
4.025.097
4.103.254
4.181.412
A-4-11-ii

SEDANG
6.037.194
6.218.310
6.339.054
6.459.798
A-4-11-iii
9.875.531
10.171.797
10.369.307
10.566.818
A-4-12-i
DEMAM RINGAN
1.532.986
1.578.975
1.609.635
1.640.295
A-4-12-ii
DEMAM SEDANG
2.198.736
2.264.699
2.308.673
2.352.648
A-4-12-iii
DEMAM BERAT
2.516.293
2.591.781
2.642.107
2.692.433
10
A-4-13-i
1.916.232
1.973.719
2.012.044
2.050.369
11
A-4-13-ii
2.299.479
2.368.463
2.414.453
2.460.442
12
A-4-13-iii
2.794.745
2.878.587
2.934.482
2.990.377
13
A-4-14-i
1.532.986
1.578.975
1.609.635
1.640.295
14
A-4-14-ii
2.434.702
2.507.743
2.556.437
2.605.131
15
A-4-14-iii
2.772.448
2.855.621
2.911.070
2.966.519
16
A-4-15-i
INFEKSI HIV RINGAN
2.299.479
2.368.463
2.414.453
2.460.442
17
A-4-15-ii
INFEKSI HIV SEDANG
3.449.218
3.552.695
3.621.679
3.690.664
18
A-4-15-iii
INFEKSI HIV BERAT
4.797.050
4.940.962
5.036.903
5.132.844
19
B-1-01-i
25.493.308
26.258.107
26.767.974
27.277.840
20
B-1-01-ii
28.125.935
28.969.713
29.532.231
30.094.750
21
B-1-01-iii
49.338.677
50.818.837
51.805.611
52.792.384
22
B-1-10-i
3.305.121
3.404.275
3.470.377
3.536.479
23
B-1-10-ii
8.423.040
8.675.731
8.844.192
9.012.653
24
B-1-10-iii
14.661.180
15.101.015
15.394.239
15.687.463
25
B-1-11-i
2.259.482
2.327.266
2.372.456
2.417.646
26
B-1-11-ii
5.671.513
5.841.658
5.955.088
6.068.519
27
B-1-11-iii
7.110.670
7.323.990
7.466.203
7.608.416
28
B-1-12-i
4.819.556
4.964.143
5.060.534
5.156.925
29
B-1-12-ii
10.329.488
10.639.373
10.845.963
11.052.553
30
B-1-12-iii
12.571.377
12.948.518
13.199.945
13.451.373

LAIN-LAIN RINGAN
LAIN-LAIN SEDANG
LAIN-LAIN BERAT

(RINGAN)
(SEDANG)
(BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT
- 801 No
Kode
INA-CBG
31
B-1-13-i
32
B-1-13-ii
33
B-1-13-iii
34
B-1-14-i
35
B-1-14-ii
36
B-1-14-iii
37
B-4-10-i
38
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.158.148
3.252.892
3.316.055
3.379.218
5.144.165
5.298.490
5.401.373
5.504.256
7.583.942
7.811.461
7.963.140
8.114.818
4.288.543
4.417.199
4.502.970
4.588.741
4.769.725
4.912.817
5.008.211
5.103.606
7.461.668
7.685.518
7.834.751
7.983.985
1.199.364
1.235.345
1.259.332
1.283.320
B-4-10-ii
1.916.232
1.973.719
2.012.044
2.050.369
39
B-4-10-iii
2.929.692
3.017.583
3.076.176
3.134.770
40
B-4-11-i
2.896.934
2.983.842
3.041.780
3.099.719
41
B-4-11-ii
4.404.062
4.536.184
4.624.266
4.712.347
42
B-4-11-iii
4.743.328
4.885.628
4.980.495
5.075.361
43
B-4-12-i
2.541.861
2.618.117
2.668.954
2.719.791
44
B-4-12-ii
3.603.733
3.711.845
3.783.920
3.855.994
45
B-4-12-iii
7.004.179
7.214.304
7.354.388
7.494.471
46
B-4-13-i
2.299.479
2.368.463
2.414.453
2.460.442
47
B-4-13-ii
3.588.463
3.696.117
3.767.886
3.839.655
48
B-4-13-iii
5.446.525
5.609.921
5.718.852
5.827.782
49
B-4-14-i
2.299.479
2.368.463
2.414.453
2.460.442
50
B-4-14-ii
2.682.725
2.763.207
2.816.862
2.870.516
51
B-4-14-iii
3.579.026
3.686.396
3.757.977
3.829.557
52
C-4-10-i
2.239.228
2.306.405
2.351.190
2.395.974
53
C-4-10-ii
4.350.586
4.481.103
4.568.115
4.655.127
54
C-4-10-iii
LEUKEMIA AKUT BERAT
7.281.683
7.500.134
7.645.767
7.791.401
55
C-4-11-i
2.299.479
2.368.463
2.414.453
2.460.442
56
C-4-11-ii
3.065.972
3.157.951
3.219.270
3.280.590
57
C-4-11-iii
5.212.511
5.368.886
5.473.137
5.577.387
58
C-4-12-i
RADIOTERAPI RINGAN
1.532.986
1.578.975
1.609.635
1.640.295
59
C-4-12-ii
RADIOTERAPI SEDANG
4.220.773
4.347.396
4.431.812
4.516.227
60
C-4-12-iii
RADIOTERAPI BERAT
8.569.015
8.826.086
8.997.466
9.168.846
61
C-4-13-i
KEMOTERAPI RINGAN
1.532.986
1.578.975
1.609.635
1.640.295
62
C-4-13-ii
KEMOTERAPI SEDANG
3.065.972
3.157.951
3.219.270
3.280.590
63
C-4-13-iii
KEMOTERAPI BERAT
4.011.597
4.131.945
4.212.177
4.292.409

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT

PANCREAS RINGAN
PANCREAS SEDANG
PANCREAS BERAT
(RINGAN)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT
- 802 No
Kode
INA-CBG
64
C-4-14-i
65
C-4-14-ii
66
C-4-14-iii
67
D-1-10-i
68
D-1-10-ii
69
D-1-10-iii
70
D-1-11-i
71
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.987.873
2.047.509
2.087.266
2.127.024
2.904.806
2.991.951
3.050.047
3.108.143
4.428.293
4.561.142
4.649.708
4.738.274
16.312.788
16.802.172
17.128.428
17.454.683
24.845.628
25.590.997
26.087.909
26.584.822
33.672.615
34.682.793
35.356.245
36.029.698
3.352.953
3.453.542
3.520.601
3.587.660
D-1-11-ii
8.745.118
9.007.471
9.182.374
9.357.276
72
D-1-11-iii
12.390.395
12.762.107
13.009.914
13.257.722
73
D-1-20-i
4.130.132
4.254.036
4.336.638
4.419.241
74
D-1-20-ii
9.292.796
9.571.580
9.757.436
9.943.292
75
D-1-20-iii
16.798.267
17.302.215
17.638.181
17.974.146
76
D-4-10-i
1.472.527
1.516.703
1.546.153
1.575.604
77
D-4-10-ii
2.973.309
3.062.509
3.121.975
3.181.441
78
D-4-10-iii
3.832.465
3.947.439
4.024.088
4.100.737
79
D-4-11-i
3.353.407
3.454.009
3.521.077
3.588.145
80
D-4-11-ii
5.993.440
6.173.243
6.293.112
6.412.981
81
D-4-11-iii
8.205.378
8.451.540
8.615.647
8.779.755
82
D-4-12-i
1.965.689
2.024.660
2.063.973
2.103.287
83
D-4-12-ii
2.726.604
2.808.402
2.862.934
2.917.466
84
D-4-12-iii
4.186.701
4.312.302
4.396.036
4.479.770
85
D-4-13-i
1.532.986
1.578.975
1.609.635
1.640.295
86
D-4-13-ii
2.299.479
2.368.463
2.414.453
2.460.442
87
D-4-13-iii
2.682.725
2.763.207
2.816.862
2.870.516
88
D-4-14-i
1.847.061
1.902.473
1.939.414
1.976.355
89
D-4-14-ii
4.312.436
4.441.809
4.528.058
4.614.306
90
D-4-14-iii
5.144.139
5.298.463
5.401.346
5.504.229
91
E-1-01-i
3.674.729
3.784.971
3.858.466
3.931.960
92
E-1-01-ii
4.813.546
4.957.952
5.054.223
5.150.494
93
E-1-01-iii
10.910.013
11.237.313
11.455.514
11.673.714
94
E-1-10-i
3.744.352
3.856.683
3.931.570
4.006.457
95
E-1-10-ii
4.544.765
4.681.108
4.772.003
4.862.898
96
E-1-10-iii
9.579.026
9.866.397
10.057.978
10.249.558

RINGAN
SEDANG
BERAT
TULANG RINGAN
TULANG SEDANG
TULANG BERAT


RINGAN
SEDANG
BERAT
- 803 No
Kode
INA-CBG
97
E-1-20-i
98
E-1-20-ii
99
E-1-20-iii
100
E-4-10-i
101
E-4-10-ii
102
E-4-10-iii
103
E-4-11-i
104
E-4-11-ii
105
E-4-11-iii
106
E-4-12-i
107
E-4-12-ii
108
E-4-12-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.336.038
4.466.119
4.552.840
4.639.560
5.807.422
5.981.644
6.097.793
6.213.941
12.867.606
13.253.634
13.510.986
13.768.338
1.916.232
1.973.719
2.012.044
2.050.369
2.725.286
2.807.044
2.861.550
2.916.056
5.209.330
5.365.610
5.469.797
5.573.983
1.634.947
1.683.995
1.716.694
1.749.393
3.093.039
3.185.830
3.247.691
3.309.552
5.100.564
5.253.581
5.355.592
5.457.603
1.953.533
2.012.139
2.051.210
2.090.281
3.393.655
3.495.465
3.563.338
3.631.211
5.541.579
5.707.827
5.818.658
5.929.490
2.060.595
2.122.413
2.163.625
2.204.837
3.538.056
3.644.198
3.714.959
3.785.720
6.121.731
6.305.383
6.427.818
6.550.252

RINGAN
SEDANG
BERAT

RINGAN
SEDANG
BERAT
109
E-4-13-i
110
E-4-13-ii
111
E-4-13-iii
112
F-4-10-i
SCHIZOFRENIA RINGAN
2.519.467
2.595.051
2.645.441
2.695.830
113
F-4-10-ii
SCHIZOFRENIA SEDANG
2.797.950
2.881.888
2.937.847
2.993.806
114
F-4-10-iii
SCHIZOFRENIA BERAT
4.142.426
4.266.699
4.349.547
4.432.396
115
F-4-11-i
2.322.339
2.392.009
2.438.456
2.484.902
116
F-4-11-ii
2.705.745
2.786.917
2.841.032
2.895.147
117
F-4-11-iii
DEPRESI MAYOR BERAT
3.469.754
3.573.847
3.643.242
3.712.637
1.149.739
1.184.232
1.207.226
1.230.221
1.641.665
1.690.915
1.723.748
1.756.581
3.561.316
3.668.156
3.739.382
3.810.609

IMPULSE RINGAN
IMPULSE SEDANG
IMPULSE BERAT
118
F-4-12-i
119
F-4-12-ii
120
F-4-12-iii
121
F-4-13-i
1.876.802
1.933.107
1.970.643
2.008.179
122
F-4-13-ii
2.485.369
2.559.930
2.609.637
2.659.345
123
F-4-13-iii
3.204.566
3.300.703
3.364.794
3.428.885
124
F-4-14-i
DEPRESI RINGAN
1.313.762
1.353.175
1.379.450
1.405.725
125
F-4-14-ii
DEPRESI SEDANG
1.685.166
1.735.721
1.769.424
1.803.127
126
F-4-14-iii
DEPRESI BERAT
2.267.466
2.335.490
2.380.839
2.426.188
127
F-4-15-i
1.561.988
1.608.848
1.640.087
1.671.327
128
F-4-15-ii
2.299.479
2.368.463
2.414.453
2.460.442
129
F-4-15-iii
3.028.555
3.119.411
3.179.982
3.240.554
- 804 No
Kode
INA-CBG
130
F-4-16-i
131
F-4-16-ii
132
F-4-16-iii
133
F-4-17-i
134
F-4-17-ii
135
F-4-17-iii
136
F-4-18-i
137
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.364.216
3.465.143
3.532.427
3.599.712
3.910.817
4.028.142
4.106.358
4.184.575
5.220.288
5.376.897
5.481.303
5.585.708
776.758
800.060
815.596
831.131
2.276.603
2.344.901
2.390.433
2.435.965
2.428.968
2.501.837
2.550.416
2.598.996
2.915.989
3.003.469
3.061.789
3.120.109
F-4-18-ii
3.208.412
3.304.664
3.368.833
3.433.001
138
F-4-18-iii
4.946.047
5.094.428
5.193.349
5.292.270
139
F-4-19-i
2.236.289
2.303.377
2.348.103
2.392.829
140
F-4-19-ii
2.863.625
2.949.534
3.006.807
3.064.079
141
F-4-19-iii
3.565.252
3.672.209
3.743.514
3.814.819
142
G-1-01-i
7.109.639
7.322.928
7.465.121
7.607.314
143
G-1-01-ii
12.033.921
12.394.938
12.635.617
12.876.295
144
G-1-01-iii
23.296.327
23.995.216
24.461.143
24.927.069
145
G-1-10-i
3.548.069
3.654.511
3.725.472
3.796.433
146
G-1-10-ii
5.008.991
5.159.260
5.259.440
5.359.620
147
G-1-10-iii
5.936.724
6.114.826
6.233.560
6.352.294
148
G-1-11-i
4.092.803
4.215.587
4.297.443
4.379.299
149
G-1-11-ii
8.404.879
8.657.026
8.825.123
8.993.221
150
G-1-11-iii
17.599.053
18.127.024
18.479.005
18.830.986
151
G-1-12-i
3.182.995
3.278.485
3.342.145
3.405.804
152
G-1-12-ii
7.287.150
7.505.764
7.651.507
7.797.250
153
G-1-12-iii
12.852.934
13.238.522
13.495.581
13.752.639
154
G-1-13-i
839.455
864.639
881.428
898.217
155
G-1-13-ii
2.254.684
2.322.324
2.367.418
2.412.512
156
G-1-13-iii
5.087.516
5.240.142
5.341.892
5.443.642
4.010.844
4.131.169
4.211.386
4.291.603
5.418.782
5.581.345
5.689.721
5.798.097
13.267.250
13.665.268
13.930.613
14.195.958

RINGAN
SEDANG
BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

RINGAN
SEDANG
BERAT
157
G-1-20-i
158
G-1-20-ii
159
G-1-20-iii
160
G-1-30-i
5.115.471
5.268.935
5.371.244
5.473.554
161
G-1-30-ii
13.351.869
13.752.425
14.019.463
14.286.500
162
G-1-30-iii
17.187.982
17.703.621
18.047.381
18.391.140
- 805 No
Kode
INA-CBG
163
G-4-10-i
164
G-4-10-ii
165
G-4-10-iii
166
G-4-11-i
167
G-4-11-ii
168
G-4-11-iii
169
G-4-12-i
170
G-4-12-ii
171
G-4-12-iii
172
G-4-13-i
173
G-4-13-ii
174
G-4-13-iii
175
G-4-14-i
176
G-4-14-ii
177
G-4-14-iii
178
G-4-15-i
179
G-4-15-ii
180
G-4-15-iii
181
G-4-16-i
182
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.299.479
2.368.463
2.414.453
2.460.442
2.682.725
2.763.207
2.816.862
2.870.516
4.098.460
4.221.414
4.303.383
4.385.353
3.793.975
3.907.795
3.983.674
4.059.554
4.401.011
4.533.042
4.621.062
4.709.082
6.449.758
6.643.251
6.772.246
6.901.241
2.837.560
2.922.686
2.979.438
3.036.189
3.575.325
3.682.585
3.754.091
3.825.598
5.192.734
5.348.516
5.452.371
5.556.226
1.578.799
1.626.163
1.657.739
1.689.315
2.682.725
2.763.207
2.816.862
2.870.516
3.171.362
3.266.503
3.329.930
3.393.358
2.887.388
2.974.010
3.031.758
3.089.506
4.750.728
4.893.250
4.988.265
5.083.279
5.948.020
6.126.461
6.245.421
6.364.381
2.955.326
3.043.986
3.103.092
3.162.199
3.571.068
3.678.200
3.749.622
3.821.043
4.412.866
4.545.252
4.633.510
4.721.767
1.916.232
1.973.719
2.012.044
2.050.369
G-4-16-ii
2.865.743
2.951.715
3.009.030
3.066.345
183
G-4-16-iii
5.200.811
5.356.836
5.460.852
5.564.868
184
G-4-17-i
2.738.471
2.820.625
2.875.395
2.930.164
185
G-4-17-ii
3.398.563
3.500.520
3.568.492
3.636.463
186
G-4-17-iii
5.696.020
5.866.901
5.980.821
6.094.742
187
G-4-18-i
2.299.479
2.368.463
2.414.453
2.460.442
188
G-4-18-ii
3.297.055
3.395.966
3.461.907
3.527.848
189
G-4-18-iii
3.492.894
3.597.681
3.667.538
3.737.396
190
G-4-19-i
1.916.232
1.973.719
2.012.044
2.050.369
191
G-4-19-ii
3.883.503
4.000.008
4.077.678
4.155.348

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
DEGENERATIF RINGAN
DEGENERATIF SEDANG
DEGENERATIF BERAT
RINGAN
SEDANG
BERAT
TRAUMATIK RINGAN
TRAUMATIK SEDANG
TRAUMATIK BERAT
DENGAN INFARK BERAT
TANPA INFARK RINGAN
TANPA INFARK SEDANG
TANPA INFARK BERAT

PERIFER RINGAN
PERIFER SEDANG
PERIFER BERAT
PERSARAFAN RINGAN
PERSARAFAN SEDANG
PERSARAFAN BERAT
RINGAN
SEDANG
- 806 No
Kode
INA-CBG
192
G-4-19-iii
193
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

5.792.953
5.966.742
6.082.601
6.198.460
G-4-20-i
1.341.363
1.381.604
1.408.431
1.435.258
194
G-4-20-ii
1.904.736
1.961.879
1.999.973
2.038.068
195
G-4-20-iii
3.248.022
3.345.463
3.410.423
3.475.383
196
G-4-21-i
1.554.333
1.600.963
1.632.049
1.663.136
197
G-4-21-ii
3.219.178
3.315.754
3.380.137
3.444.521
198
G-4-21-iii
3.792.572
3.906.349
3.982.200
4.058.052
199
G-4-22-i
1.532.986
1.578.975
1.609.635
1.640.295
200
G-4-22-ii
1.916.232
1.973.719
2.012.044
2.050.369
201
G-4-22-iii
2.198.419
2.264.372
2.308.340
2.352.309
202
G-4-23-i
1.532.986
1.578.975
1.609.635
1.640.295
203
G-4-23-ii
1.916.232
1.973.719
2.012.044
2.050.369
204
G-4-23-iii
2.739.118
2.821.292
2.876.074
2.930.857
205
G-4-24-i
1.532.986
1.578.975
1.609.635
1.640.295
206
G-4-24-ii
1.916.232
1.973.719
2.012.044
2.050.369
207
G-4-24-iii
TRAUMA KEPALA BERAT
4.026.755
4.147.558
4.228.093
4.308.628
208
G-4-25-i
GEGAR OTAK RINGAN
1.456.636
1.500.335
1.529.468
1.558.600
209
G-4-25-ii
GEGAR OTAK SEDANG
1.833.937
1.888.955
1.925.634
1.962.312
210
G-4-25-iii
GEGAR OTAK BERAT
2.392.780
2.464.564
2.512.419
2.560.275
211
G-4-26-i
2.299.479
2.368.463
2.414.453
2.460.442
212
G-4-26-ii
2.682.725
2.763.207
2.816.862
2.870.516
213
G-4-26-iii
5.120.947
5.274.576
5.376.995
5.479.414
214
H-1-20-i
2.203.501
2.269.606
2.313.676
2.357.746
215
H-1-20-ii
4.018.334
4.138.884
4.219.250
4.299.617
216
H-1-20-iii
5.464.683
5.628.623
5.737.917
5.847.211
2.157.437
2.222.161
2.265.309
2.308.458
2.459.479
2.533.263
2.582.453
2.631.642

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)

RINGAN
SEDANG
217
H-1-30-i
218
H-1-30-ii
219
H-1-30-iii
4.103.551
4.226.658
4.308.729
4.390.800
220
H-4-10-i
2.299.479
2.368.463
2.414.453
2.460.442
221
H-4-10-ii
3.832.465
3.947.439
4.024.088
4.100.737
222
H-4-10-iii
6.248.049
6.435.491
6.560.452
6.685.413
223
H-4-11-i
1.565.692
1.612.663
1.643.977
1.675.291
224
H-4-11-ii
1.749.428
1.801.911
1.836.900
1.871.888
225
H-4-11-iii
2.501.519
2.576.564
2.626.595
2.676.625
- 807 No
Kode
INA-CBG
226
H-4-12-i
227
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.172.336
2.237.506
2.280.952
2.324.399
H-4-12-ii
2.942.571
3.030.848
3.089.699
3.148.551
228
H-4-12-iii
4.909.479
5.056.763
5.154.953
5.253.142
229
I-1-01-i
33.072.334
34.064.505
34.725.951
35.387.398
230
I-1-01-ii
33.800.098
34.814.101
35.490.103
36.166.105
231
I-1-01-iii
53.352.807
54.953.391
56.020.447
57.087.503
232
I-1-02-i
18.348.341
18.898.791
19.265.758
19.632.725
233
I-1-02-ii
23.669.359
24.379.440
24.852.827
25.326.215
234
I-1-02-iii
29.173.862
30.049.078
30.632.555
31.216.032
235
I-1-03-i
11.299.561
11.638.548
11.864.539
12.090.530
236
I-1-03-ii
15.487.993
15.952.633
16.262.393
16.572.153
237
I-1-03-iii
22.715.724
23.397.195
23.851.510
24.305.824
238
I-1-04-i
13.785.133
14.198.687
14.474.390
14.750.093
239
I-1-04-ii
17.707.248
18.238.466
18.592.611
18.946.756
240
I-1-04-iii
37.748.177
38.880.622
39.635.586
40.390.550
241
I-1-05-i
24.284.569
25.013.106
25.498.797
25.984.488
242
I-1-05-ii
29.141.482
30.015.727
30.598.556
31.181.386
243
I-1-05-iii
40.098.496
41.301.451
42.103.420
42.905.390
244
I-1-06-i
11.447.207
11.790.623
12.019.567
12.248.511
245
I-1-06-ii
17.276.553
17.794.849
18.140.380
18.485.911
246
I-1-06-iii
22.241.100
22.908.333
23.353.155
23.797.977
15.053.944
15.505.562
15.806.641
16.107.720
18.572.098
19.129.261
19.500.703
19.872.145
20.262.038
20.869.899
21.275.140
21.680.381
2.863.627
2.949.536
3.006.809
3.064.081
3.184.067
3.279.589
3.343.270
3.406.952
4.237.023
4.364.134
4.448.874
4.533.614
8.776.530
9.039.825
9.215.356
9.390.887
12.177.845
12.543.180
12.786.737
13.030.294
247
I-1-07-i
248
I-1-07-ii
249
I-1-07-iii
250
I-1-11-i
251
I-1-11-ii
252
I-1-11-iii
253
I-1-12-i
254
I-1-12-ii

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
KATETERISASI RINGAN
KATETERISASI SEDANG
KATETERISASI BERAT
RINGAN
SEDANG
BERAT

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
- 808 No
Kode
INA-CBG
255
I-1-12-iii
256
I-1-13-i
257
I-1-13-ii
258
I-1-13-iii
259
I-1-14-i
260
I-1-14-ii
261
I-1-14-iii
262
I-1-15-i
263
264
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
16.985.218
17.494.775
17.834.479
18.174.184
5.162.664
5.317.544
5.420.798
5.524.051
6.006.444
6.186.637
6.306.766
6.426.895
10.949.345
11.277.826
11.496.813
11.715.799
18.887.998
19.454.638
19.832.398
20.210.158
23.475.083
24.179.335
24.648.837
25.118.339
30.760.453
31.683.267
32.298.476
32.913.685
3.701.142
3.812.176
3.886.199
3.960.222
I-1-15-ii
10.841.595
11.166.843
11.383.675
11.600.507
I-1-15-iii
56.117.717
57.801.248
58.923.602
60.045.957
8.094.856
8.337.702
8.499.599
8.661.496
21.046.626
21.678.025
22.098.957
22.519.890
24.276.767
25.005.070
25.490.605
25.976.140
2.596.085
2.673.968
2.725.890
2.777.811
5.377.434
5.538.757
5.646.306
5.753.855
31.175.092
32.110.345
32.733.847
33.357.349
3.097.599
3.190.527
3.252.478
3.314.430
5.575.677
5.742.948
5.854.461
5.965.975
7.434.237
7.657.264
7.805.949
7.954.633
9.183.656
9.459.166
9.642.839
9.826.512
19.103.861
19.676.976
20.059.054
20.441.131
29.604.045
30.492.167
31.084.248
31.676.329
12.349.948
12.720.446
12.967.445
13.214.444
17.151.424
17.665.967
18.008.996
18.352.024
21.491.521
22.136.267
22.566.097
22.995.927

KOMPLEKS BERAT
KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

DARAH VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
265
I-1-16-i
266
I-1-16-ii
267
I-1-16-iii
268
I-1-17-i
269
I-1-17-ii
270
I-1-17-iii
271
I-1-20-i
272
I-1-20-ii
273
I-1-20-iii
274
I-1-30-i
275
I-1-30-ii
276
I-1-30-iii
277
I-1-40-i
278
I-1-40-ii
279
I-1-40-iii
280
I-4-10-i
3.591.724
3.699.475
3.771.310
3.843.144
281
I-4-10-ii
5.671.396
5.841.538
5.954.966
6.068.394
282
I-4-10-iii
8.181.483
8.426.928
8.590.558
8.754.187
283
I-4-11-i
4.258.845
4.386.610
4.471.787
4.556.964
- 809 No
Kode
INA-CBG
284
I-4-11-ii
285
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.270.337
5.428.447
5.533.854
5.639.261
I-4-11-iii
9.327.246
9.607.063
9.793.608
9.980.153
286
I-4-12-i
3.730.305
3.842.215
3.916.821
3.991.427
287
I-4-12-ii
5.323.135
5.482.829
5.589.292
5.695.755
288
I-4-12-iii
6.457.712
6.651.443
6.780.598
6.909.752
289
I-4-13-i
3.350.840
3.451.365
3.518.382
3.585.399
290
I-4-13-ii
4.868.086
5.014.129
5.111.491
5.208.852
291
I-4-13-iii
9.964.408
10.263.341
10.462.629
10.661.917
292
I-4-14-i
2.083.913
2.146.430
2.188.108
2.229.787
293
I-4-14-ii
2.438.486
2.511.641
2.560.410
2.609.180
294
I-4-14-iii
3.778.842
3.892.208
3.967.784
4.043.361
295
I-4-15-i
3.065.972
3.157.951
3.219.270
3.280.590
296
I-4-15-ii
4.389.090
4.520.763
4.608.545
4.696.327
297
I-4-15-iii
5.002.507
5.152.582
5.252.633
5.352.683
298
I-4-16-i
2.299.479
2.368.463
2.414.453
2.460.442
299
I-4-16-ii
3.726.663
3.838.463
3.912.996
3.987.530
300
I-4-16-iii
4.694.934
4.835.782
4.929.681
5.023.579
301
I-4-17-i
HIPERTENSI RINGAN
2.057.986
2.119.726
2.160.885
2.202.045
302
I-4-17-ii
HIPERTENSI SEDANG
2.914.313
3.001.742
3.060.029
3.118.315
303
I-4-17-iii
HIPERTENSI BERAT
3.545.401
3.651.763
3.722.671
3.793.579
304
I-4-18-i
3.030.822
3.121.747
3.182.363
3.242.980
305
I-4-18-ii
4.643.017
4.782.307
4.875.168
4.968.028
306
I-4-18-iii
6.259.531
6.447.317
6.572.507
6.697.698
307
I-4-19-i
2.372.016
2.443.176
2.490.616
2.538.057
308
I-4-19-ii
3.885.287
4.001.846
4.079.552
4.157.257
309
I-4-19-iii
4.631.227
4.770.164
4.862.788
4.955.413
310
I-4-20-i
2.878.777
2.965.140
3.022.716
3.080.291
311
I-4-20-ii
3.316.566
3.416.063
3.482.394
3.548.726
312
I-4-20-iii
4.401.635
4.533.684
4.621.717
4.709.750
313
I-4-21-i
3.828.307
3.943.157
4.019.723
4.096.289
314
I-4-21-ii
4.775.565
4.918.832
5.014.343
5.109.855
315
I-4-21-iii
6.514.883
6.710.330
6.840.628
6.970.925
316
I-4-22-i
2.491.102
2.565.835
2.615.657
2.665.479

VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT


RINGAN
SEDANG
KONGENITAL BERAT
RINGAN
SEDANG
BERAT
- 810 No
Kode
INA-CBG
317
I-4-22-ii
318
I-4-22-iii
319
I-4-23-i
320
I-4-23-ii
321
I-4-23-iii
322
I-4-24-i
323
I-4-24-ii
324
I-4-24-iii
325
J-1-01-i
326
J-1-01-ii
327
J-1-01-iii
328
J-1-02-i
329
J-1-02-ii
330
J-1-02-iii
331
J-1-10-i
332
J-1-10-ii
333
J-1-10-iii
334
J-1-20-i
335
J-1-20-ii
336
J-1-20-iii
337
J-1-30-i
338
J-1-30-ii
339
J-1-30-iii
340
J-4-10-i
341
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.870.495
2.956.610
3.014.020
3.071.430
4.187.975
4.313.614
4.397.373
4.481.133
1.887.150
1.943.765
1.981.508
2.019.251
2.316.986
2.386.495
2.432.835
2.479.175
4.527.179
4.662.994
4.753.538
4.844.081
2.250.825
2.318.350
2.363.367
2.408.383
5.619.688
5.788.279
5.900.673
6.013.067
7.105.081
7.318.233
7.460.335
7.602.436
18.485.086
19.039.639
19.409.341
19.779.042
20.134.391
20.738.423
21.141.111
21.543.799
29.855.557
30.751.223
31.348.334
31.945.446
8.361.630
8.612.479
8.779.711
8.946.944
8.957.533
9.226.259
9.405.410
9.584.561
13.236.682
13.633.783
13.898.516
14.163.250
3.262.829
3.360.714
3.425.970
3.491.227
7.880.917
8.117.345
8.274.963
8.432.582
13.954.133
14.372.757
14.651.839
14.930.922
2.820.128
2.904.732
2.961.135
3.017.537
4.101.654
4.224.703
4.306.736
4.388.769
6.167.620
6.352.649
6.476.001
6.599.354
1.901.768
1.958.821
1.996.857
2.034.892
10.325.329
10.635.089
10.841.595
11.048.102
31.140.739
32.074.961
32.697.776
33.320.590
2.433.298
2.506.297
2.554.963
2.603.629
J-4-10-ii
3.479.324
3.583.703
3.653.290
3.722.876
342
J-4-10-iii
5.263.697
5.421.608
5.526.882
5.632.156
343
J-4-11-i
1.384.699
1.426.240
1.453.934
1.481.628
344
J-4-11-ii
1.927.470
1.985.294
2.023.843
2.062.392
345
J-4-11-iii
2.762.113
2.844.976
2.900.219
2.955.461
346
J-4-12-i
EMBOLI PARU RINGAN
2.347.569
2.417.996
2.464.947
2.511.899
347
J-4-12-ii
EMBOLI PARU SEDANG
3.040.021
3.131.222
3.192.022
3.252.823

RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
- 811 No
Kode
INA-CBG
348
J-4-12-iii
349
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
EMBOLI PARU BERAT
4.059.641
4.181.430
4.262.623
4.343.816
J-4-13-i
3.261.853
3.359.709
3.424.946
3.490.183
350
J-4-13-ii
4.794.925
4.938.772
5.034.671
5.130.569
351
J-4-13-iii
7.795.830
8.029.705
8.185.621
8.341.538
352
J-4-14-i
TUMOR PARU RINGAN
2.299.479
2.368.463
2.414.453
2.460.442
353
J-4-14-ii
TUMOR PARU SEDANG
3.723.578
3.835.285
3.909.757
3.984.229
354
J-4-14-iii
TUMOR PARU BERAT
4.427.145
4.559.959
4.648.502
4.737.045
355
J-4-15-i
2.299.479
2.368.463
2.414.453
2.460.442
356
J-4-15-ii
2.740.113
2.822.316
2.877.118
2.931.921
357
J-4-15-iii
3.720.872
3.832.499
3.906.916
3.981.334
358
J-4-16-i
1.916.232
1.973.719
2.012.044
2.050.369
359
J-4-16-ii
2.682.725
2.763.207
2.816.862
2.870.516
360
J-4-16-iii
4.839.354
4.984.535
5.081.322
5.178.109
361
J-4-17-i
1.916.232
1.973.719
2.012.044
2.050.369
362
J-4-17-ii
2.299.479
2.368.463
2.414.453
2.460.442
363
J-4-17-iii
4.227.460
4.354.283
4.438.833
4.523.382
364
J-4-18-i
1.532.986
1.578.975
1.609.635
1.640.295
365
J-4-18-ii
2.107.856
2.171.091
2.213.248
2.255.406
366
J-4-18-iii
2.219.443
2.286.026
2.330.415
2.374.804
367
J-4-19-i
2.682.725
2.763.207
2.816.862
2.870.516
368
J-4-19-ii
3.065.972
3.157.951
3.219.270
3.280.590
369
J-4-19-iii
4.803.204
4.947.300
5.043.365
5.139.429
370
J-4-20-i
2.682.725
2.763.207
2.816.862
2.870.516
371
J-4-20-ii
3.065.972
3.157.951
3.219.270
3.280.590
372
J-4-20-iii
7.394.510
7.616.345
7.764.236
7.912.126
373
J-4-21-i
1.532.986
1.578.975
1.609.635
1.640.295
374
J-4-21-ii
3.782.156
3.895.621
3.971.264
4.046.907
375
J-4-21-iii
5.394.592
5.556.429
5.664.321
5.772.213
376
K-1-10-i
4.130.132
4.254.036
4.336.638
4.419.241
377
K-1-10-ii
5.763.870
5.936.786
6.052.063
6.167.341
378
K-1-10-iii
6.750.484
6.952.999
7.088.008
7.223.018
379
K-1-11-i
3.551.278
3.657.816
3.728.842
3.799.867
380
K-1-11-ii
4.662.399
4.802.271
4.895.519
4.988.767

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT

USUS BESAR (RINGAN)
USUS BESAR (SEDANG)
USUS BESAR (BERAT)
- 812 No
Kode
INA-CBG
381
K-1-11-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
11.832.252
12.187.219
12.423.864
12.660.509
1.910.316
1.967.625
2.005.831
2.044.038
2.489.732
2.564.424
2.614.219
2.664.014
4.952.601
5.101.179
5.200.231
5.299.283
382
K-1-12-i
383
K-1-12-ii
384
K-1-12-iii
385
K-1-13-i
2.169.857
2.234.953
2.278.350
2.321.747
386
K-1-13-ii
3.790.117
3.903.820
3.979.622
4.055.425
387
K-1-13-iii
4.053.393
4.174.995
4.256.063
4.337.130
3.506.617
3.611.816
3.681.948
3.752.080
4.118.919
4.242.487
4.324.865
4.407.243
10.141.973
10.446.232
10.649.071
10.851.911

RINGAN
SEDANG
BERAT
388
K-1-14-i
389
K-1-14-ii
390
K-1-14-iii
391
K-1-20-i
6.803.866
7.007.982
7.144.059
7.280.136
392
K-1-20-ii
9.496.402
9.781.294
9.971.222
10.161.150
393
K-1-20-iii
20.284.764
20.893.307
21.299.002
21.704.697
394
K-1-30-i
4.478.643
4.613.002
4.702.575
4.792.148
395
K-1-30-ii
8.260.263
8.508.071
8.673.276
8.838.482
396
K-1-30-iii
12.864.300
13.250.229
13.507.515
13.764.801
397
K-1-40-i
4.499.338
4.634.318
4.724.304
4.814.291
398
K-1-40-ii
4.951.074
5.099.606
5.198.628
5.297.649
399
K-1-40-iii
8.210.880
8.457.206
8.621.424
8.785.641
400
K-1-50-i
3.431.909
3.534.866
3.603.504
3.672.143
401
K-1-50-ii
4.444.484
4.577.819
4.666.708
4.755.598
402
K-1-50-iii
PROSEDUR ANAL BERAT
6.309.985
6.499.285
6.625.485
6.751.684
403
K-4-10-i
2.599.424
2.677.407
2.729.395
2.781.384
404
K-4-10-ii
3.110.364
3.203.675
3.265.882
3.328.089
405
K-4-10-iii
12.879.976
13.266.375
13.523.975
13.781.574
406
K-4-11-i
1.532.986
1.578.975
1.609.635
1.640.295
407
K-4-11-ii
2.299.479
2.368.463
2.414.453
2.460.442
408
K-4-11-iii
4.178.982
4.304.351
4.387.931
4.471.510
409
K-4-12-i
1.532.986
1.578.975
1.609.635
1.640.295
410
K-4-12-ii
2.290.257
2.358.965
2.404.770
2.450.575
411
K-4-12-iii
5.496.454
5.661.348
5.771.277
5.881.206
412
K-4-13-i

(RINGAN)
2.299.479
2.368.463
2.414.453
2.460.442

(RINGAN)
(SEDANG)
(BERAT)
- 813 No
Kode
INA-CBG
413
K-4-13-ii
414
K-4-13-iii
415
K-4-14-i
416
K-4-14-ii
417
K-4-14-iii
418
K-4-15-i
419
K-4-15-ii
420
K-4-15-iii
421
K-4-16-i
422
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.978.391
3.067.743
3.127.311
3.186.879
4.871.345
5.017.485
5.114.912
5.212.339
1.916.232
1.973.719
2.012.044
2.050.369
2.593.421
2.671.223
2.723.092
2.774.960
3.922.796
4.040.480
4.118.936
4.197.392
1.916.232
1.973.719
2.012.044
2.050.369
3.603.040
3.711.131
3.783.192
3.855.252
5.126.477
5.280.271
5.382.801
5.485.330
1.916.232
1.973.719
2.012.044
2.050.369
K-4-16-ii
2.299.479
2.368.463
2.414.453
2.460.442
423
K-4-16-iii
2.806.813
2.891.017
2.947.153
3.003.290
424
K-4-17-i
1.532.986
1.578.975
1.609.635
1.640.295
425
K-4-17-ii
2.236.655
2.303.755
2.348.488
2.393.221
426
K-4-17-iii
2.976.760
3.066.062
3.125.598
3.185.133
427
K-4-18-i
1.532.986
1.578.975
1.609.635
1.640.295
428
K-4-18-ii
2.379.830
2.451.225
2.498.822
2.546.418
429
K-4-18-iii
2.815.327
2.899.787
2.956.093
3.012.400
430
L-1-20-i
15.687.430
16.158.053
16.471.802
16.785.550
431
L-1-20-ii
16.319.252
16.808.829
17.135.214
17.461.600
432
L-1-20-iii
25.002.978
25.753.067
26.253.127
26.753.186
433
L-1-30-i
7.115.357
7.328.817
7.471.124
7.613.431
434
L-1-30-ii
10.306.617
10.615.815
10.821.948
11.028.080
435
L-1-30-iii
10.870.265
11.196.373
11.413.778
11.631.183
436
L-1-40-i
2.872.974
2.959.163
3.016.623
3.074.082
437
L-1-40-ii
6.466.202
6.660.188
6.789.512
6.918.836
438
L-1-40-iii
10.958.504
11.287.259
11.506.429
11.725.599
439
L-1-50-i
5.162.664
5.317.544
5.420.798
5.524.051
440
L-1-50-ii
9.292.796
9.571.580
9.757.436
9.943.292
441
L-1-50-iii
11.236.305
11.573.394
11.798.120
12.022.847
442
L-4-10-i
2.299.479
2.368.463
2.414.453
2.460.442
443
L-4-10-ii
2.682.725
2.763.207
2.816.862
2.870.516

(SEDANG)
RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
- 814 No
Kode
INA-CBG
444
L-4-10-iii
445
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.426.924
5.589.732
5.698.270
5.806.809
L-4-11-i
2.174.888
2.240.135
2.283.633
2.327.130
446
L-4-11-ii
2.979.559
3.068.946
3.128.537
3.188.128
447
L-4-11-iii
8.080.191
8.322.597
8.484.200
8.645.804
448
L-4-12-i
2.299.479
2.368.463
2.414.453
2.460.442
449
L-4-12-ii
3.373.869
3.475.085
3.542.562
3.610.040
450
L-4-12-iii
5.657.579
5.827.306
5.940.458
6.053.610
451
L-4-13-i
1.443.313
1.486.613
1.515.479
1.544.345
452
L-4-13-ii
1.664.226
1.714.152
1.747.437
1.780.721
453
L-4-13-iii
2.496.468
2.571.362
2.621.292
2.671.221
454
L-4-14-i
1.532.986
1.578.975
1.609.635
1.640.295
455
L-4-14-ii
2.299.479
2.368.463
2.414.453
2.460.442
456
L-4-14-iii
3.595.277
3.703.135
3.775.040
3.846.946
457
M-1-01-i
7.473.904
7.698.121
7.847.599
7.997.077
458
M-1-01-ii
8.342.085
8.592.348
8.759.190
8.926.031
459
M-1-01-iii
11.718.370
12.069.921
12.304.288
12.538.656
460
M-1-02-i
5.293.430
5.452.233
5.558.101
5.663.970
461
M-1-02-ii
8.690.806
8.951.530
9.125.346
9.299.162
462
M-1-02-iii
15.738.650
16.210.810
16.525.583
16.840.356
463
M-1-03-i
13.422.928
13.825.615
14.094.074
14.362.533
464
M-1-03-ii
15.708.751
16.180.013
16.494.188
16.808.363
465
M-1-03-iii
16.004.260
16.484.388
16.804.473
17.124.558
466
M-1-04-i
3.491.917
3.596.675
3.666.513
3.736.351
467
M-1-04-ii
4.476.601
4.610.899
4.700.432
4.789.964
468
M-1-04-iii
5.601.623
5.769.672
5.881.704
5.993.736
469
M-1-05-i
5.439.736
5.602.928
5.711.723
5.820.518
470
M-1-05-ii
6.286.877
6.475.484
6.601.221
6.726.959
471
M-1-05-iii
10.708.264
11.029.512
11.243.678
11.457.843
472
M-1-07-i
6.004.707
6.184.849
6.304.943
6.425.037
473
M-1-07-ii
8.044.431
8.285.764
8.446.653
8.607.542
474
M-1-07-iii
16.387.270
16.878.888
17.206.633
17.534.378
475
M-1-10-i
3.752.827
3.865.411
3.940.468
4.015.525


TULANG WAJAH RINGAN
- 815 No
Kode
INA-CBG
476
M-1-10-ii
477
M-1-10-iii
478
M-1-20-i
479
M-1-20-ii
480
M-1-20-iii
481
M-1-30-i
482
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
13.940.051
14.358.252
14.637.053
14.915.854
17.051.339
17.562.879
17.903.906
18.244.933
3.712.515
3.823.891
3.898.141
3.972.391
5.299.282
5.458.261
5.564.246
5.670.232
10.300.649
10.609.669
10.815.682
11.021.695
2.220.639
2.287.258
2.331.671
2.376.084
M-1-30-ii
4.588.405
4.726.057
4.817.825
4.909.594
483
M-1-30-iii
PROSEDUR KAKI BERAT
6.844.933
7.050.281
7.187.180
7.324.078
484
M-1-40-i
2.243.783
2.311.097
2.355.972
2.400.848
485
M-1-40-ii
4.130.132
4.254.036
4.336.638
4.419.241
486
M-1-40-iii
7.227.730
7.444.562
7.589.117
7.733.671
487
M-1-50-i
2.971.608
3.060.756
3.120.189
3.179.621
488
M-1-50-ii
5.981.917
6.161.375
6.281.013
6.400.651
489
M-1-50-iii
8.260.263
8.508.071
8.673.276
8.838.482
490
M-1-60-i
2.242.626
2.309.905
2.354.758
2.399.610
491
M-1-60-ii
4.489.753
4.624.445
4.714.240
4.804.036
492
M-1-60-iii
7.813.758
8.048.171
8.204.446
8.360.721
493
M-1-70-i
3.004.218
3.094.344
3.154.429
3.214.513
494
M-1-70-ii
6.130.092
6.313.995
6.436.597
6.559.199
495
M-1-70-iii
9.882.449
10.178.922
10.376.571
10.574.220
496
M-1-80-i
2.420.586
2.493.204
2.541.616
2.590.028
497
M-1-80-ii
3.659.432
3.769.215
3.842.403
3.915.592
498
M-1-80-iii
8.424.960
8.677.709
8.846.208
9.014.707
499
M-4-10-i
1.532.986
1.578.975
1.609.635
1.640.295
500
M-4-10-ii
2.338.952
2.409.120
2.455.899
2.502.678
501
M-4-10-iii
FRAKTUR FEMUR BERAT
4.966.640
5.115.639
5.214.972
5.314.305
502
M-4-11-i
2.028.829
2.089.694
2.130.270
2.170.847
503
M-4-11-ii
4.654.436
4.794.069
4.887.157
4.980.246
504
M-4-11-iii
8.261.514
8.509.360
8.674.590
8.839.820
505
M-4-12-i
1.532.986
1.578.975
1.609.635
1.640.295
506
M-4-12-ii
2.789.266
2.872.944
2.928.729
2.984.515

TULANG WAJAH SEDANG
TULANG WAJAH BERAT

RINGAN
SEDANG
BERAT

SELAIN KAKI (BERAT)

PANGGUL RINGAN
PANGGUL SEDANG
PANGGUL BERAT
PELVIS RINGAN
PELVIS SEDANG
- 816 No
Kode
INA-CBG
507
M-4-12-iii
508
M-4-13-i
509
M-4-13-ii
510
M-4-13-iii
511
M-4-14-i
512
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.586.170
5.753.755
5.865.479
5.977.202
2.830.027
2.914.928
2.971.529
3.028.129
3.832.465
3.947.439
4.024.088
4.100.737
8.418.622
8.671.181
8.839.554
9.007.926
3.065.972
3.157.951
3.219.270
3.280.590
M-4-14-ii
3.980.453
4.099.867
4.179.476
4.259.085
513
M-4-14-iii
OSTEOMIELITIS BERAT
5.962.290
6.141.159
6.260.405
6.379.651
514
M-4-15-i
1.912.838
1.970.224
2.008.480
2.046.737
515
M-4-15-ii
2.550.612
2.627.131
2.678.143
2.729.155
516
M-4-15-iii
6.515.190
6.710.646
6.840.950
6.971.253
517
M-4-16-i
1.916.232
1.973.719
2.012.044
2.050.369
518
M-4-16-ii
3.065.972
3.157.951
3.219.270
3.280.590
519
M-4-16-iii
5.700.955
5.871.984
5.986.003
6.100.022
520
M-4-17-i
1.916.232
1.973.719
2.012.044
2.050.369
521
M-4-17-ii
2.682.725
2.763.207
2.816.862
2.870.516
522
M-4-17-iii
3.746.568
3.858.965
3.933.897
4.008.828
523
M-4-18-i
2.246.122
2.313.506
2.358.428
2.403.350
524
M-4-18-ii
3.065.972
3.157.951
3.219.270
3.280.590
525
M-4-18-iii
3.809.292
3.923.570
3.999.756
4.075.942
526
M-4-19-i
1.670.022
1.720.123
1.753.523
1.786.924
527
M-4-19-ii
2.812.852
2.897.238
2.953.495
3.009.752
528
M-4-19-iii
5.493.708
5.658.519
5.768.394
5.878.268
529
M-4-20-i
1.532.986
1.578.975
1.609.635
1.640.295
530
M-4-20-ii
2.299.479
2.368.463
2.414.453
2.460.442
531
M-4-20-iii
2.548.365
2.624.815
2.675.783
2.726.750
532
M-4-21-i
1.532.986
1.578.975
1.609.635
1.640.295
533
M-4-21-ii
2.000.932
2.060.960
2.100.979
2.140.997
534
M-4-21-iii
4.877.428
5.023.751
5.121.299
5.218.848
535
N-1-01-i
4.147.845
4.272.281
4.355.237
4.438.194
536
N-1-01-ii
5.609.867
5.778.163
5.890.360
6.002.558
537
N-1-01-iii
11.894.587
12.251.424
12.489.316
12.727.208

PELVIS BERAT

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
RINGAN
SEDANG
BERAT
ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
- 817 No
Kode
INA-CBG
538
N-1-11-i
539
N-1-11-ii
540
N-1-11-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.722.273
5.893.941
6.008.386
6.122.832
7.739.245
7.971.422
8.126.207
8.280.992
16.409.501
16.901.786
17.229.976
17.558.166
3.097.599
3.190.527
3.252.479
3.314.431
7.206.344
7.422.534
7.566.661
7.710.788
13.134.011
13.528.031
13.790.712
14.053.392
541
N-1-12-i
542
N-1-12-ii
543
N-1-12-iii
544
N-1-20-i
4.193.904
4.319.721
4.403.599
4.487.477
545
N-1-20-ii
8.315.021
8.564.471
8.730.772
8.897.072
546
N-1-20-iii
9.511.630
9.796.979
9.987.211
10.177.444
547
N-1-30-i
4.989.389
5.139.071
5.238.858
5.338.646
548
N-1-30-ii
7.581.999
7.809.459
7.961.099
8.112.739
549
N-1-30-iii
8.728.131
8.989.975
9.164.538
9.339.100
550
N-1-40-i
4.495.928
4.630.806
4.720.724
4.810.643
551
N-1-40-ii
6.094.391
6.277.222
6.399.110
6.520.998
552
N-1-40-iii
7.087.952
7.300.591
7.442.350
7.584.109
553
N-4-10-i
1.916.232
1.973.719
2.012.044
2.050.369
554
N-4-10-ii
2.565.889
2.642.865
2.694.183
2.745.501
555
N-4-10-iii
5.616.269
5.784.757
5.897.082
6.009.407
556
N-4-11-i
1.467.457
1.511.480
1.540.830
1.570.179
557
N-4-11-ii
2.479.967
2.554.366
2.603.965
2.653.564
558
N-4-11-iii
2.874.349
2.960.579
3.018.066
3.075.553
559
N-4-12-i
1.532.986
1.578.975
1.609.635
1.640.295
560
N-4-12-ii
2.299.479
2.368.463
2.414.453
2.460.442
561
N-4-12-iii
3.817.891
3.932.427
4.008.785
4.085.143
562
N-4-13-i
BATU URIN RINGAN
2.022.480
2.083.154
2.123.604
2.164.053
563
N-4-13-ii
BATU URIN SEDANG
2.438.350
2.511.500
2.560.267
2.609.034
564
N-4-13-iii
BATU URIN BERAT
6.004.987
6.185.137
6.305.236
6.425.336
1.327.850
1.367.685
1.394.242
1.420.799
2.044.722
2.106.064
2.146.958
2.187.852
3.315.887
3.415.364
3.481.681
3.547.999
565
N-4-14-i
566
N-4-14-ii
567
N-4-14-iii

URIN BAWAH RINGAN
URIN BAWAH SEDANG
URIN BAWAH BERAT
RINGAN
SEDANG
BERAT
GINJAL RINGAN
GINJAL SEDANG
GINJAL BERAT

(RINGAN)
(SEDANG)
(BERAT)
- 818 No
Kode
INA-CBG
568
N-4-15-i
569
N-4-15-ii
570
N-4-15-iii
571
N-4-16-i
572
N-4-16-ii
573
N-4-16-iii
574
O-6-10-i
575
O-6-10-ii
576
O-6-10-iii
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
584
585
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.969.969
2.029.068
2.068.467
2.107.867
2.703.410
2.784.513
2.838.581
2.892.649
3.085.079
3.177.631
3.239.333
3.301.035
2.556.747
2.633.450
2.684.585
2.735.720
3.065.972
3.157.951
3.219.270
3.280.590
6.447.283
6.640.701
6.769.647
6.898.592
3.775.164
3.888.419
3.963.922
4.039.425
4.191.007
4.316.737
4.400.558
4.484.378
4.698.169
4.839.114
4.933.078
5.027.041
1.973.036
2.032.227
2.071.687
2.111.148
2.531.225
2.607.161
2.657.786
2.708.410
4.289.640
4.418.329
4.504.122
4.589.915
1.718.129
1.769.672
1.804.035
1.838.398
2.063.468
2.125.372
2.166.642
2.207.911
2.592.452
2.670.226
2.722.075
2.773.924
1.721.875
1.773.531
1.807.968
1.842.406
O-6-13-ii
2.537.705
2.613.836
2.664.590
2.715.345
O-6-13-iii
2.999.176
3.089.151
3.149.135
3.209.118
38.517.557
39.673.083
40.443.434
41.213.786
47.659.451
49.089.235
50.042.424
50.995.613
55.938.835
57.617.001
58.735.777
59.854.554
46.667.026
48.067.037
49.000.377
49.933.718
53.531.882
55.137.839
56.208.476
57.279.114
61.164.003
62.998.923
64.222.203
65.445.483
2.581.332
2.658.772
2.710.399
2.762.025
3.613.865
3.722.281
3.794.558
3.866.836
5.692.657
5.863.437
5.977.290
6.091.143
23.053.110
23.744.703
24.205.765
24.666.828
29.917.966
30.815.505
31.413.865
32.012.224
586
P-8-01-i
587
P-8-01-ii
588
P-8-01-iii
589
P-8-02-i
590
P-8-02-ii
591
P-8-02-iii
592
P-8-03-i
593
P-8-03-ii
594
P-8-03-iii
595
P-8-04-i
596
P-8-04-ii

SALURAN URIN RINGAN
SALURAN URIN SEDANG
SALURAN URIN BERAT
RINGAN
SEDANG
BERAT
&KURET RINGAN
KURET SEDANG
KURET BERAT

- 819 No
Kode
INA-CBG
597
P-8-04-iii
598
P-8-05-i
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii
603
P-8-06-iii
604
P-8-07-i
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
614
P-8-11-ii
615
P-8-11-iii
616
P-8-12-i
617
P-8-12-ii
618
P-8-12-iii
619
P-8-13-i
620
P-8-13-ii
621
P-8-13-iii
622
P-8-14-i
623
P-8-14-ii
624
P-8-14-iii
Deskripsi (INA-CBG)
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
RINGAN
SEDANG
BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
42.894.833
44.181.678
45.039.575
45.897.471
12.535.534
12.911.600
13.162.310
13.413.021
17.767.429
18.300.452
18.655.801
19.011.149
26.177.922
26.963.259
27.486.818
28.010.376
2.065.066
2.127.018
2.168.319
2.209.620
5.196.247
5.352.134
5.456.059
5.559.984
9.665.611
9.955.580
10.148.892
10.342.204
3.613.865
3.722.281
3.794.558
3.866.836
10.132.408
10.436.380
10.639.028
10.841.676
13.422.928
13.825.615
14.094.074
14.362.533
2.618.902
2.697.469
2.749.847
2.802.225
3.717.900
3.829.437
3.903.795
3.978.153
5.248.533
5.405.989
5.510.960
5.615.931
1.624.764
1.673.507
1.706.002
1.738.497
2.353.707
2.424.318
2.471.392
2.518.467
4.621.021
4.759.651
4.852.072
4.944.492
4.576.026
4.713.307
4.804.827
4.896.348
9.742.233
10.034.500
10.229.345
10.424.190
9.946.335
10.244.725
10.443.652
10.642.578
2.158.849
2.223.614
2.266.791
2.309.968
3.356.635
3.457.334
3.524.467
3.591.600
3.960.120
4.078.923
4.158.126
4.237.328
1.115.809
1.149.284
1.171.600
1.193.916
2.064.797
2.126.741
2.168.037
2.209.332
3.088.124
3.180.768
3.242.530
3.304.293
2.038.700
2.099.861
2.140.635
2.181.409
4.162.448
4.287.322
4.370.571
4.453.820
4.566.190
4.703.176
4.794.500
4.885.824
- 820 No
Kode
INA-CBG
625
P-8-15-i
626
P-8-15-ii
627
P-8-15-iii
628
P-8-16-i
629
P-8-16-ii
630
P-8-16-iii
631
P-8-17-i
632
P-8-17-ii
633
P-8-17-iii
634
S-4-10-i
635
S-4-10-ii
636
S-4-10-iii
637
S-4-11-i
638
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.533.166
1.579.161
1.609.824
1.640.488
3.064.396
3.156.327
3.217.615
3.278.903
3.599.607
3.707.595
3.779.587
3.851.580
1.387.878
1.429.514
1.457.271
1.485.029
1.968.764
2.027.826
2.067.202
2.106.577
2.555.552
2.632.218
2.683.329
2.734.441
915.996
943.476
961.796
980.116
3.042.629
3.133.908
3.194.761
3.255.613
6.141.353
6.325.594
6.448.421
6.571.248
1.532.986
1.578.975
1.609.635
1.640.295
1.916.232
1.973.719
2.012.044
2.050.369
2.490.773
2.565.496
2.615.312
2.665.127
958.116
986.860
1.006.022
1.025.184
S-4-11-ii
1.458.271
1.502.019
1.531.184
1.560.350
639
S-4-11-iii
2.359.227
2.430.004
2.477.189
2.524.373
640
S-4-12-i
1.149.739
1.184.232
1.207.226
1.230.221
641
S-4-12-ii
1.532.986
1.578.975
1.609.635
1.640.295
642
S-4-12-iii
2.994.043
3.083.864
3.143.745
3.203.626
643
S-4-13-i
1.532.986
1.578.975
1.609.635
1.640.295
644
S-4-13-ii
2.709.975
2.791.275
2.845.474
2.899.674
645
S-4-13-iii
5.517.854
5.683.390
5.793.747
5.904.104
646
S-4-14-i
934.020
962.041
980.721
999.402
647
S-4-14-ii
1.984.172
2.043.697
2.083.381
2.123.064
648
S-4-14-iii
3.762.697
3.875.578
3.950.832
4.026.086
649
S-4-15-i
706.408
727.600
741.728
755.857
650
S-4-15-ii
1.333.233
1.373.230
1.399.894
1.426.559
651
S-4-15-iii
1.726.846
1.778.651
1.813.188
1.847.725
652
S-4-16-i
LUKA BAKAR RINGAN
2.682.725
2.763.207
2.816.862
2.870.516
653
S-4-16-ii
LUKA BAKAR SEDANG
3.788.882
3.902.549
3.978.326
4.054.104
654
S-4-16-iii
LUKA BAKAR BERAT
6.765.637
6.968.606
7.103.919
7.239.232
1.430.482
1.473.396
1.502.006
1.530.615
1.916.232
1.973.719
2.012.044
2.050.369
655
S-4-17-i
656
S-4-17-ii

ASPIRASI RINGAN
ASPIRASI SEDANG
ASPIRASI BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT

PASIEN RINGAN
PASIEN SEDANG
PASIEN BERAT

- 821 No
Kode
INA-CBG
657
S-4-17-iii
658
T-1-10-i
659
T-1-10-ii
660
T-1-10-iii
661
T-4-10-i
662
T-4-10-ii
663
T-4-10-iii
664
T-4-11-i
665
T-4-11-ii
666
T-4-11-iii
667
T-4-12-i
668
T-4-12-ii
669
T-4-12-iii
670
U-1-10-i
671
672
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.124.795
3.218.539
3.281.035
3.343.531
1.476.652
1.520.952
1.550.485
1.580.018
1.983.043
2.042.535
2.082.196
2.121.856
3.607.802
3.716.036
3.788.193
3.860.349
645.930
665.308
678.226
691.145
1.230.999
1.267.929
1.292.549
1.317.169
1.789.538
1.843.224
1.879.015
1.914.806
638.787
657.951
670.727
683.503
1.005.270
1.035.428
1.055.533
1.075.639
1.619.193
1.667.769
1.700.153
1.732.537
1.341.363
1.381.604
1.408.431
1.435.258
2.027.396
2.088.218
2.128.766
2.169.314
3.153.899
3.248.516
3.311.594
3.374.672
1.427.758
1.470.590
1.499.146
1.527.701
U-1-10-ii
2.913.427
3.000.830
3.059.099
3.117.367
U-1-10-iii
12.580.768
12.958.191
13.209.806
13.461.421
6.195.197
6.381.053
6.504.957
6.628.861
8.260.263
8.508.071
8.673.276
8.838.482
13.877.977
14.294.317
14.571.876
14.849.436

DOKTER RINGAN
DOKTER SEDANG
DOKTER BERAT

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
673
U-1-11-i
674
U-1-11-ii
675
U-1-11-iii
676
U-1-12-i
3.785.952
3.899.531
3.975.250
4.050.969
677
U-1-12-ii
9.292.796
9.571.580
9.757.436
9.943.292
678
U-1-12-iii
12.066.872
12.428.878
12.670.215
12.911.553
679
U-1-13-i
4.130.132
4.254.036
4.336.638
4.419.241
680
U-1-13-ii
4.659.909
4.799.706
4.892.904
4.986.103
681
U-1-13-iii
8.985.619
9.255.187
9.434.900
9.614.612
2.278.877
2.347.243
2.392.821
2.438.398
2.796.640
2.880.539
2.936.472
2.992.405
3.314.097
3.413.520
3.479.802
3.546.084

682
U-1-14-i
683
U-1-14-ii
684
U-1-14-iii
685
U-1-15-i
1.338.471
1.378.625
1.405.395
1.432.164
686
U-1-15-ii
1.901.874
1.958.930
1.996.968
2.035.005
687
U-1-15-iii
3.747.719
3.860.151
3.935.105
4.010.060
- 822 No
Kode
INA-CBG
688
U-1-20-i
689
U-1-20-ii
690
U-1-20-iii
691
U-1-30-i
692
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.462.042
3.565.903
3.635.144
3.704.385
6.162.435
6.347.308
6.470.557
6.593.805
15.202.952
15.659.040
15.963.099
16.267.158
2.969.828
3.058.923
3.118.320
3.177.716
U-1-30-ii
4.009.268
4.129.546
4.209.732
4.289.917
693
U-1-30-iii
7.859.319
8.095.098
8.252.284
8.409.471
694
U-4-10-i
2.764.414
2.847.347
2.902.635
2.957.923
695
U-4-10-ii
6.929.806
7.137.700
7.276.296
7.414.892
696
U-4-10-iii
10.109.077
10.412.350
10.614.531
10.816.713
697
U-4-11-i
1.532.986
1.578.975
1.609.635
1.640.295
698
U-4-11-ii
2.299.479
2.368.463
2.414.453
2.460.442
699
U-4-11-iii
3.180.170
3.275.575
3.339.179
3.402.782
700
U-4-12-i
1.532.986
1.578.975
1.609.635
1.640.295
701
U-4-12-ii
1.787.108
1.840.722
1.876.464
1.912.206
702
U-4-12-iii
2.841.421
2.926.664
2.983.492
3.040.321
703
U-4-13-i
1.506.046
1.551.227
1.581.348
1.611.469
704
U-4-13-ii
1.750.866
1.803.392
1.838.409
1.873.427
705
U-4-13-iii
1.987.980
2.047.620
2.087.379
2.127.139
706
U-4-14-i
1.916.232
1.973.719
2.012.044
2.050.369
707
U-4-14-ii
2.299.479
2.368.463
2.414.453
2.460.442
708
U-4-14-iii
3.852.026
3.967.587
4.044.627
4.121.668
709
U-4-15-i
1.532.986
1.578.975
1.609.635
1.640.295
710
U-4-15-ii
1.916.232
1.973.719
2.012.044
2.050.369
711
U-4-15-iii
2.683.245
2.763.743
2.817.408
2.871.073
712
V-1-10-i
4.481.426
4.615.869
4.705.497
4.795.126
713
V-1-10-ii
5.162.664
5.317.544
5.420.798
5.524.051
714
V-1-10-iii
9.809.062
10.103.334
10.299.516
10.495.697
715
V-1-11-i
5.162.664
5.317.544
5.420.798
5.524.051
716
V-1-11-ii
5.761.620
5.934.469
6.049.701
6.164.934
717
V-1-11-iii
8.532.077
8.788.040
8.958.681
9.129.323
2.788.254
2.871.902
2.927.667
2.983.432
10.655.780
10.975.453
11.188.569
11.401.685
12.441.594
12.814.842
13.063.674
13.312.506
718
V-1-12-i
719
V-1-12-ii
720
V-1-12-iii


DAN TELINGA RINGAN
DAN TELINGA SEDANG
DAN TELINGA BERAT


KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

- 823 No
Kode
INA-CBG
721
V-1-13-i
722
V-1-13-ii
723
V-1-13-iii
724
V-1-14-i
725
V-1-14-ii
726
V-1-14-iii
727
V-1-15-i
728
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.226.089
4.352.872
4.437.394
4.521.916
8.030.782
8.271.706
8.432.321
8.592.937
12.390.395
12.762.107
13.009.914
13.257.722
5.094.600
5.247.438
5.349.330
5.451.222
7.409.659
7.631.949
7.780.142
7.928.335
10.072.353
10.374.524
10.575.971
10.777.418
2.401.820
2.473.875
2.521.911
2.569.948
V-1-15-ii
4.575.000
4.712.250
4.803.750
4.895.250
729
V-1-15-iii
8.042.762
8.284.045
8.444.900
8.605.756
730
V-4-10-i
3.867.537
3.983.563
4.060.914
4.138.264
731
V-4-10-ii
4.995.386
5.145.247
5.245.155
5.345.063
732
V-4-10-iii
9.547.059
9.833.470
10.024.412
10.215.353
733
V-4-11-i
1.966.787
2.025.791
2.065.127
2.104.462
734
V-4-11-ii
2.873.790
2.960.004
3.017.480
3.074.956
735
V-4-11-iii
4.741.564
4.883.811
4.978.642
5.073.473
736
W-1-01-i
5.783.318
5.956.817
6.072.484
6.188.150
737
W-1-01-ii
6.965.732
7.174.704
7.314.018
7.453.333
738
W-1-01-iii
15.385.918
15.847.495
16.155.214
16.462.932
739
W-1-10-i
1.610.647
1.658.966
1.691.179
1.723.392
740
W-1-10-ii
3.005.732
3.095.904
3.156.018
3.216.133
741
W-1-10-iii
4.916.423
5.063.916
5.162.244
5.260.573
742
W-1-11-i
1.672.927
1.723.114
1.756.573
1.790.031
743
W-1-11-ii
3.226.451
3.323.244
3.387.773
3.452.302
744
W-1-11-iii
6.195.197
6.381.053
6.504.957
6.628.861
745
W-1-12-i
1.520.105
1.565.708
1.596.111
1.626.513
746
W-1-12-ii
1.728.331
1.780.180
1.814.747
1.849.314
747
W-1-12-iii
2.654.934
2.734.582
2.787.680
2.840.779
748
W-1-13-i
1.809.285
1.863.563
1.899.749
1.935.934
749
W-1-13-ii
1.964.362
2.023.292
2.062.580
2.101.867
750
W-1-13-iii
2.638.500
2.717.655
2.770.425
2.823.195
751
W-1-20-i
4.929.785
5.077.678
5.176.274
5.274.870
752
W-1-20-ii
6.934.482
7.142.517
7.281.206
7.419.896

NON KOMPLEK (BERAT)

RINGAN
SEDANG
BERAT

SERVIK RINGAN
SERVIK SEDANG
SERVIK BERAT
ENDOSKOP RINGAN
ENDOSKOP SEDANG
ENDOSKOP BERAT
- 824 No
Kode
INA-CBG
753
W-1-20-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
8.760.206
9.023.012
9.198.216
9.373.420
2.691.168
2.771.903
2.825.727
2.879.550
4.292.553
4.421.329
4.507.180
4.593.031
11.414.953
11.757.402
11.985.701
12.214.000
754
W-1-30-i
755
W-1-30-ii
756
W-1-30-iii
757
W-4-10-i
2.006.937
2.067.145
2.107.284
2.147.423
758
W-4-10-ii
2.712.601
2.793.979
2.848.231
2.902.483
759
W-4-10-iii
6.131.944
6.315.902
6.438.541
6.561.180
760
W-4-11-i
1.916.232
1.973.719
2.012.044
2.050.369
761
W-4-11-ii
3.065.972
3.157.951
3.219.270
3.280.590
762
W-4-11-iii
3.726.064
3.837.846
3.912.368
3.986.889
1.532.986
1.578.975
1.609.635
1.640.295
2.107.856
2.171.091
2.213.248
2.255.406
2.350.025
2.420.526
2.467.526
2.514.527

763
W-4-12-i
764
W-4-12-ii
765
W-4-12-iii
766
W-4-13-i
ABORTUS RINGAN
840.708
865.929
882.743
899.557
767
W-4-13-ii
ABORTUS SEDANG
1.149.739
1.184.232
1.207.226
1.230.221
768
W-4-13-iii
ABORTUS BERAT
1.532.986
1.578.975
1.609.635
1.640.295
769
W-4-14-i
1.149.739
1.184.232
1.207.226
1.230.221
770
W-4-14-ii
1.478.751
1.523.113
1.552.688
1.582.263
771
W-4-14-iii
1.860.721
1.916.542
1.953.757
1.990.971
772
W-4-15-i
958.749
987.511
1.006.686
1.025.861
773
W-4-15-ii
1.066.311
1.098.301
1.119.627
1.140.953
774
W-4-15-iii
1.476.409
1.520.702
1.550.230
1.579.758
775
W-4-16-i
1.149.739
1.184.232
1.207.226
1.230.221
776
W-4-16-ii
1.532.986
1.578.975
1.609.635
1.640.295
777
W-4-16-iii
2.090.018
2.152.718
2.194.519
2.236.319
778
W-4-17-i
939.056
967.228
986.009
1.004.790
779
W-4-17-ii
1.532.986
1.578.975
1.609.635
1.640.295
780
W-4-17-iii
2.900.104
2.987.108
3.045.110
3.103.112
781
Z-4-10-i
REHABILITASI RINGAN
2.630.422
2.709.335
2.761.943
2.814.552
782
Z-4-10-ii
REHABILITASI SEDANG
3.491.506
3.596.251
3.666.081
3.735.911
783
Z-4-10-iii
REHABILITASI BERAT
4.960.017
5.108.818
5.208.018
5.307.218
784
Z-4-11-i
2.296.069
2.364.951
2.410.873
2.456.794
785
Z-4-11-ii
2.763.960
2.846.879
2.902.158
2.957.437
786
Z-4-11-iii
4.373.076
4.504.268
4.591.730
4.679.191
- 825 No
Kode
INA-CBG
787
Z-4-12-i
788
Z-4-12-ii
789
Z-4-12-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.149.739
1.184.232
1.207.226
1.230.221
2.342.556
2.412.833
2.459.684
2.506.535
2.977.018
3.066.329
3.125.869
3.185.409
- 826 b. RawatJalan
No
Kode
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
775.006
798.256
813.756
829.256
1.005.304
1.035.463
1.055.569
1.075.675
1.869.494
1.925.579
1.962.969
2.000.359
1.544.956
1.591.304
1.622.204
1.653.103
1.290.677
1.329.398
1.355.211
1.381.025
452.517
466.093
475.143
484.193
1.009.054
1.039.326
1.059.507
1.079.688

207.327
213.547
217.694
221.840
C-3-10-0
565.560
582.527
593.838
605.149
10
C-3-11-0

KANDUNG KEMIH
894.454
921.288
939.177
957.066
11
C-3-12-0
202.771
208.854
212.909
216.965
196.904
202.812
206.750
210.688
1.676.251
1.726.538
1.760.063
1.793.588
1.536.351
1.582.441
1.613.168
1.643.895

LAPAROSKOPI
PANKREAS
LAPAROSKOPI
EMPEDU

OVARIUM
GASTROINTESTINAL
GINJAL ATAU PROSTAT
12
C-3-13-0
13
C-3-14-0
14
C-3-15-0
15
C-3-16-0
348.407
358.860
365.828
372.796
16
C-3-17-0

LEHER
231.123
238.057
242.679
247.302
17
C-3-18-0
102.470
105.544
107.594
109.643
18
C-3-19-0

MYELOMA ATAU TESTIS
144.913
149.261
152.159
155.057
19
C-3-20-0
2.885.957
2.972.536
3.030.255
3.087.974
20
C-3-21-0
165.372
170.333
173.641
176.948
21
C-3-22-0
726.072
747.854
762.376
776.897
22
C-3-23-0
117.608
121.136
123.488
125.840
23
D-2-10-0

TULANG
996.390
1.026.282
1.046.209
1.066.137
24
D-2-11-0
1.247.650
1.285.080
1.310.033
1.334.986
1.046.425
1.077.818
1.098.747
1.119.675
229.659
236.549
241.142
245.735
166.348
171.338
174.665
177.992
431.886
444.843
453.481
462.118
256.192
263.877
269.001
274.125
185.730
191.302
195.017
198.731
185.730
191.302
195.017
198.731
25
D-2-21-0
26
D-2-22-0
27
D-3-10-0
28
D-3-11-0
29
E-2-10-0
30
E-2-21-0
31
E-2-22-0
PROSEDUR LIMPA
TYMUS
TYMUS
TULANG
PEMBENTUK DARAH
PARATIROID
THYROGLOSSAL
- 827 No
Kode
INA-CBG
32
E-3-10-0
33
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

ENDOKRIN
215.992
222.472
226.792
231.112
F-3-10-0
TERAPI SHOCK
301.302
310.341
316.367
322.393
34
F-5-10-0
369.193
380.268
387.652
395.036
35
F-5-11-0
TERAPI KELOMPOK
243.449
250.752
255.621
260.490
36
F-5-12-0
311.534
320.880
327.110
333.341
37
F-5-13-0
263.848
271.764
277.041
282.318
38
F-5-14-0
177.007
182.317
185.857
189.397
39
F-5-15-0
166.055
171.037
174.358
177.679
40
F-5-16-0
172.963
178.151
181.611
185.070
41
G-2-10-0
145.648
150.017
152.930
155.843
42
G-2-11-0
1.262.536
1.300.412
1.325.663
1.350.914
43
G-2-12-0

EKSTRAKRANIAL
1.829.726
1.884.618
1.921.212
1.957.807
44
G-2-13-0
448.873
462.339
471.316
480.294
45
G-2-21-0
818.668
843.228
859.601
875.975
46
G-2-22-0
743.011
765.301
780.161
795.022
47
G-2-31-0
1.226.033
1.262.814
1.287.334
1.311.855
48
G-2-32-0
628.463
647.317
659.886
672.456
49
G-3-10-0
249.441
256.924
261.913
266.902
50
G-3-11-0
332.208
342.174
348.818
355.462
51
G-3-12-0
544.328
560.658
571.544
582.431
52
G-3-13-0
544.390
560.722
571.610
582.497
53
H-2-21-0
714.431
735.864
750.153
764.441
54
H-2-22-0
185.730
191.302
195.017
198.731
55
H-2-23-0
185.730
191.302
195.017
198.731
56
H-2-31-0
1.183.396
1.218.898
1.242.565
1.266.233
57
H-2-32-0
123.164
126.859
129.322
131.785
58
H-2-33-0
185.730
191.302
195.017
198.731
59
H-2-34-0
530.900
546.827
557.445
568.063
60
H-2-35-0
174.944
180.192
183.691
187.190
61
H-2-36-0
944.305
972.634
991.520
1.010.406
62
H-2-37-0

1.005.254
1.035.412
1.055.517
1.075.622
63
H-3-10-0
349.755
360.248
367.243
374.238
64
H-3-11-0
183.932
189.450
193.129
196.808

AKUT
MENTAL
PROSEDUR KRANIOTOMI

MATA
MATA
MATA
MATA
MATA
- 828 No
Kode
INA-CBG
65
H-3-12-0
66
H-3-13-0
67
I-2-11-0
68
I-2-12-0
69
I-2-13-0
70
I-2-14-0
71
I-2-15-0
Deskripsi (INA-CBG)
MATA
TORASIK
ABDOMEN
PENGGANTIAN ALAT
DARAH VENA
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
192.035
197.796
201.636
205.477
186.454
192.048
195.777
199.506
2.150.214
2.214.720
2.257.725
2.300.729
1.511.835
1.557.190
1.587.427
1.617.663
1.921.451
1.979.095
2.017.524
2.055.953
3.400.560
3.502.576
3.570.588
3.638.599
204.503
210.638
214.728
218.818
2.147.884
2.212.320
2.255.278
2.298.235
708.096
729.338
743.500
757.662
72
I-2-16-0
73
I-2-17-0
74
I-2-21-0
1.657.861
1.707.597
1.740.754
1.773.911
75
I-2-22-0
1.561.166
1.608.001
1.639.225
1.670.448
76
I-2-23-0
319.488
329.073
335.462
341.852
77
I-2-31-0
2.484.766
2.559.309
2.609.004
2.658.700
78
I-2-32-0
3.249.197
3.346.672
3.411.656
3.476.640
79
I-2-41-0
2.178.626
2.243.985
2.287.558
2.331.130
80
I-2-42-0

LAIN
2.533.013
2.609.004
2.659.664
2.710.324
81
I-3-10-0
PROSEDUR RESUSITASI
321.544
331.190
337.621
344.052
82
I-3-11-0
169.710
174.801
178.195
181.590
83
I-3-12-0
986.290
1.015.879
1.035.605
1.055.331
84
I-3-13-0
323.936
333.654
340.133
346.611
85
I-3-14-0
207.632
213.861
218.013
222.166
183.932
189.450
193.129
196.808
1.138.791
1.172.955
1.195.730
1.218.506
183.573
189.080
192.752
196.423
925.093
952.845
971.347
989.849
1.199.928
1.235.926
1.259.924
1.283.923

PACU JANTUNG

KARDIOVASKULAR
PERNAFASAN
PENDEK
86
I-3-15-0
87
J-2-10-0
88
J-2-21-0
89
J-2-22-0
90
J-2-31-0
91
J-2-32-0
892.945
919.734
937.593
955.452
92
J-3-10-0
185.730
191.302
195.017
198.731
93
J-3-11-0

PADA DADA
524.840
540.586
551.082
561.579
94
J-3-12-0
202.771
208.854
212.909
216.965
95
J-3-13-0
298.428
307.381
313.350
319.318
96
J-3-14-0
316.814
326.318
332.655
338.991
- 829 No
Kode
INA-CBG
97
J-3-15-0
98
J-3-16-0
99
J-3-17-0
100
K-2-10-0
101
K-2-11-0
102
K-2-12-0

103
K-2-13-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
277.821
286.155
291.712
297.268
316.814
326.318
332.655
338.991
185.730
191.302
195.017
198.731
534.595
550.633
561.325
572.017
1.141.578
1.175.826
1.198.657
1.221.489
876.309
902.598
920.124
937.650
1.426.240
1.469.027
1.497.552
1.526.077
185.730
191.302
195.017
198.731
185.730
191.302
195.017
198.731
2.387.075
2.458.687
2.506.429
2.554.170
802.652
826.732
842.785
858.838
185.730
191.302
195.017
198.731

PERNAFASAN
KECIL

FEMORALIS
USUS BESAR
ATAS
ATAS
104
K-2-14-0
105
K-2-21-0
106
K-2-22-0
107
K-2-31-0
108
K-2-32-0
109
K-2-41-0
884.138
910.662
928.345
946.027
110
K-2-42-0

252.609
260.187
265.240
270.292
111
K-2-51-0
585.883
603.460
615.177
626.895
112
K-2-52-0
319.488
329.073
335.462
341.852
113
K-2-53-0
185.730
191.302
195.017
198.731
114
K-3-10-0

GASTROINTESTINAL
353.432
364.035
371.104
378.172
115
K-3-11-0
212.482
218.856
223.106
227.355
116
K-3-12-0
215.483
221.948
226.257
230.567
117
K-3-13-0
185.730
191.302
195.017
198.731
497.761
512.694
522.649
532.604
240.376
247.587
252.394
257.202
318.513
328.068
334.439
340.809
1.095.060
1.127.911
1.149.813
1.171.714
701.925
722.983
737.022
751.060
316.814
326.318
332.655
338.991
319.488
329.073
335.462
341.852

GASTROINTESTINAL
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
118
K-3-14-0
119
K-3-15-0
120
K-3-16-0
121
L-2-21-0
122
L-2-22-0
123
L-2-31-0
124
L-2-32-0
125
L-2-41-0
956.669
985.369
1.004.502
1.023.636
126
L-2-42-0

214.565
221.002
225.294
229.585
127
L-2-51-0
1.432.283
1.475.252
1.503.897
1.532.543
L-2-52-0

1.095.744
1.128.616
1.150.531
1.172.446
128
- 830 No
Kode
INA-CBG
129
L-2-53-0
130
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

185.730
191.302
195.017
198.731
L-3-10-0
252.609
260.187
265.240
270.292
131
L-3-11-0
245.301
252.660
257.566
262.472
132
L-3-12-0
186.820
192.425
196.161
199.897
133
M-2-10-0
1.465.330
1.509.290
1.538.597
1.567.903
134
M-2-21-0
1.312.305
1.351.674
1.377.920
1.404.166
135
M-2-22-0
319.488
329.073
335.462
341.852
136
M-2-31-0
PROSEDUR BUNION
797.093
821.006
836.948
852.890
137
M-2-32-0
252.609
260.187
265.240
270.292
138
M-2-41-0

TULANG
252.609
260.187
265.240
270.292
139
M-2-42-0
87.056
89.668
91.409
93.150
140
M-2-51-0
185.730
191.302
195.017
198.731
141
M-2-52-0
185.730
191.302
195.017
198.731
142
M-2-61-0
PROSEDUR ARTROSKOPI
910.361
937.672
955.879
974.086
143
M-2-62-0
185.730
191.302
195.017
198.731
915.285
942.744
961.050
979.355
1.248.260
1.285.708
1.310.673
1.335.639
185.730
191.302
195.017
198.731
921.544
949.191
967.621
986.052
889.329
916.009
933.796
951.583

DAN WAJAH
PAHA
PAHA

TULANG
WAJAH
WAJAH
BAWAH
BAWAH
144
M-2-63-0
145
M-2-64-0
146
M-2-65-0
147
M-2-71-0
148
M-2-72-0
149
M-2-81-0
1.326.180
1.365.965
1.392.489
1.419.012
150
M-2-82-0
963.384
992.286
1.011.554
1.030.821
151
M-2-83-0
185.730
191.302
195.017
198.731
152
M-2-84-0
185.730
191.302
195.017
198.731
153
M-3-10-0
530.110
546.013
556.615
567.217
154
M-3-11-0
293.914
302.731
308.609
314.487
155
M-3-12-0
664.663
684.603
697.896
711.189
156
M-3-13-0
216.698
223.199
227.533
231.867
157
M-3-14-0

TERTUTUP
370.374
381.485
388.892
396.300
158
M-3-15-0
163.172
168.067
171.331
174.594
159
M-3-16-0

185.730
191.302
195.017
198.731
160
M-3-17-0
202.771
208.854
212.909
216.965
161
N-2-11-0
2.453.678
2.527.288
2.576.362
2.625.435

PERGELANGAN TANGAN
PERGELANGAN TANGAN
MUSKULOSKELETAL
SKELETAL
- 831 No
Kode
INA-CBG
162
N-2-12-0
163
N-2-21-0
164
N-2-22-0
165
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.419.428
1.462.011
1.490.400
1.518.788
1.411.946
1.454.305
1.482.544
1.510.783
319.488
329.073
335.462
341.852
N-2-23-0
319.488
329.073
335.462
341.852
166
N-2-24-0
1.032.478
1.063.452
1.084.102
1.104.751
167
N-2-31-0
869.179
895.254
912.638
930.022
168
N-2-32-0
319.488
329.073
335.462
341.852
169
N-2-41-0
319.488
329.073
335.462
341.852
170
N-2-42-0
540.315
556.525
567.331
578.138
171
N-3-10-0
319.488
329.073
335.462
341.852
172
N-3-11-0
370.172
381.278
388.681
396.085
173
N-3-12-0
286.049
294.630
300.351
306.072
174
N-3-13-0
319.488
329.073
335.462
341.852
175
N-3-14-0
274.902
283.149
288.647
294.145
176
N-3-15-0
704.918
726.066
740.164
754.262
177
O-7-10-0
117.691
121.222
123.575
125.929
178
O-7-11-0
648.155
667.600
680.563
693.526
179
O-7-12-0
236.015
243.096
247.816
252.536
180
O-7-13-0
131.167
135.102
137.725
140.348
181
P-9-10-0
174.944
180.192
183.691
187.190
182
P-9-11-0
174.944
180.192
183.691
187.190
183
P-9-12-0
174.944
180.192
183.691
187.190
184
P-9-13-0
174.944
180.192
183.691
187.190
185
P-9-14-0
174.944
180.192
183.691
187.190
186
P-9-15-0
111.513
114.858
117.088
119.319
187
P-9-16-0
174.944
180.192
183.691
187.190
188
P-9-17-0
174.191
179.417
182.901
186.385
189
Q-5-10-0
228.007
234.848
239.408
243.968
190
Q-5-11-0
170.885
176.012
179.430
182.847
191
Q-5-12-0
GIGI
150.614
155.132
158.144
161.157
192
Q-5-13-0
MEDICAL CHECK-UP
114.460
117.894
120.183
122.472
193
Q-5-14-0
125.943
129.722
132.240
134.759


DAN URETHRA
URETHRA
TRANSURETHRA
TRANSURETHRA
SALURAN KEMIH
KEMIH
KEMIH
PROSEDUR DIALISIS
CAESAR
VAGINAL/JALAN LAHIR

ASPIRASI
- 832 No
Kode
INA-CBG
194
Q-5-15-0
195
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
86.611
89.209
90.942
92.674
Q-5-16-0
VAKSINASI
97.891
100.827
102.785
104.743
196
Q-5-17-0
PASANG INFUS
84.673
87.213
88.906
90.600
197
Q-5-18-0
159.381
164.162
167.350
170.537
198
Q-5-19-0
178.178
183.523
187.087
190.651
199
Q-5-20-0
ABORSI MENGANCAM
119.427
123.010
125.398
127.787
200
Q-5-21-0
ABORSI
117.800
121.334
123.690
126.046
201
Q-5-22-0
125.943
129.722
132.240
134.759
202
Q-5-23-0
154.188
158.813
161.897
164.981
203
Q-5-24-0
105.308
108.467
110.573
112.680
204
Q-5-25-0
164.226
169.153
172.437
175.722
205
Q-5-26-0
BRONKIAL AKUT
232.450
239.424
244.073
248.722
206
Q-5-27-0
165.423
170.386
173.694
177.003
207
Q-5-28-0
134.236
138.264
140.948
143.633
208
Q-5-29-0

JANTUNG LAIN-LAIN
380.046
391.447
399.048
406.649
209
Q-5-30-0
440.432
453.645
462.453
471.262
210
Q-5-31-0
FRAKTUR
157.128
161.842
164.985
168.127
211
Q-5-32-0
SALURAN KEMIH AKUT
181.990
187.450
191.090
194.729
212
Q-5-33-0
HEMATOLOGI AKUT
190.543
196.259
200.070
203.881
213
Q-5-34-0
INFEKSI VIRUS HIV
270.680
278.800
284.214
289.627
214
Q-5-35-0
INFEKSI AKUT
306.943
316.152
322.291
328.430
215
Q-5-36-0
357.456
368.179
375.328
382.477
216
Q-5-37-0

SHOCK
182.321
187.790
191.437
195.083
217
Q-5-38-0
PARU AKUT
243.130
250.424
255.287
260.150
218
Q-5-39-0
155.586
160.253
163.365
166.477
219
Q-5-40-0
152.654
157.234
160.287
163.340
220
Q-5-41-0
211.328
217.668
221.895
226.121
221
Q-5-42-0
165.690
170.660
173.974
177.288
222
Q-5-43-0
238.603
245.761
250.533
255.305
223
Q-5-44-0
194.733
200.575
204.470
208.364
224
T-2-10-0

TERAPI DETOKSIKASI
101.005
104.035
106.055
108.075
225
U-2-10-0
1.348.022
1.388.463
1.415.423
1.442.384
226
U-2-11-0

LEHER
1.602.274
1.650.343
1.682.388
1.714.434
227
U-2-12-0
176.292
181.581
185.107
188.632
- 833 No
Kode
INA-CBG
228
U-2-13-0
229
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
231.123
238.057
242.679
247.302
U-2-14-0
429.322
442.202
450.788
459.375
230
U-2-15-0
243.931
251.249
256.128
261.007
231
U-2-21-0
284.142
292.666
298.349
304.032
232
U-2-22-0
548.985
565.455
576.434
587.414
233
U-2-23-0
719.348
740.928
755.315
769.702
234
U-2-24-0
606.254
624.442
636.567
648.692
235
U-2-25-0
231.123
238.057
242.679
247.302
236
U-2-31-0
185.730
191.302
195.017
198.731
237
U-2-32-0
231.123
238.057
242.679
247.302
238
U-3-10-0
220.966
227.595
232.014
236.434
239
U-3-11-0
234.597
241.635
246.327
251.019
240
U-3-12-0
103.738
106.851
108.925
111.000
241
U-3-13-0
228.025
234.866
239.427
243.987
242
U-3-14-0
209.508
215.793
219.984
224.174
243
U-3-15-0
182.710
188.191
191.845
195.499
244
U-3-16-0
PROSEDUR PADA GIGI
206.063
212.245
216.367
220.488
245
V-2-10-0

PROSTAT
2.010.387
2.070.699
2.110.907
2.151.114
246
V-2-11-0
226.721
233.522
238.057
242.591
723.497
745.202
759.672
774.142
319.488
329.073
335.462
341.852
319.488
329.073
335.462
341.852

(RHINOPLASTY)

RONGGA HIDUNG
TENGGOROKAN
PROSEDUR PADA PENIS

SKROTUM
SKROTUM
TRANSURETHRAL
247
V-2-12-0
248
V-2-13-0
249
V-2-14-0
250
V-2-15-0
SIRKUMSISI/SUNAT
174.944
180.192
183.691
187.190
251
V-3-10-0
364.857
375.802
383.100
390.397
252
V-3-11-0
771.861
795.017
810.454
825.891
253
V-3-12-0
445.616
458.984
467.897
476.809
254
W-2-10-0
163.172
168.067
171.331
174.594
255
W-2-11-0
417.007
429.518
437.858
446.198
256
W-2-12-0
771.861
795.017
810.454
825.891
257
W-2-13-0
123.793
127.507
129.982
132.458
258
W-2-21-0
1.551.647
1.598.196
1.629.229
1.660.262
259
W-2-22-0
163.172
168.067
171.331
174.594

PROSEDUR ABORSI
RAHIM & LEHER RAHIM
TERHALANG/TERGANGGU
TERHALANG/TERGANGGU
PANGGUL TERBUKA
PANGGUL TERBUKA
- 834 No
Kode
INA-CBG
260
W-2-23-0
Deskripsi (INA-CBG)
JALAN LAHIR
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
544.514
560.849
571.739
582.630
1.787.473
1.841.097
1.876.846
1.912.596
1.253.636
1.291.245
1.316.317
1.341.390
261
W-2-31-0
262
W-2-32-0
263
W-2-33-0
532.812
548.796
559.452
570.109
264
W-2-34-0
181.219
186.655
190.280
193.904
265
W-3-10-0
440.431
453.644
462.453
471.262
266
W-3-11-0
352.068
362.630
369.672
376.713
267
W-3-12-0
163.172
168.067
171.331
174.594
268
Z-3-10-0
1.847.327
1.902.747
1.939.693
1.976.640
269
Z-3-11-0

EMPEDU
1.411.946
1.454.305
1.482.544
1.510.783
270
Z-3-12-0
235.761
242.834
247.549
252.264
271
Z-3-13-0

LAIN-LAIN
1.438.678
1.481.838
1.510.611
1.539.385
272
Z-3-14-0
DIAGNOSTIK TIDUR
284.471
293.005
298.695
304.384
273
Z-3-15-0
185.730
191.302
195.017
198.731
274
Z-3-16-0

(MRI)
596.137
614.022
625.944
637.867
275
Z-3-17-0
PENGOBATAN NUKLIR
250.271
257.780
262.785
267.790
276
Z-3-18-0
CT-SCAN KEPALA
241.132
248.366
253.188
258.011
277
Z-3-19-0
CT SCAN LAIN-LAIN
250.971
258.500
263.520
268.539
278
Z-3-20-0
170.692
175.812
179.226
182.640
279
Z-3-21-0
163.172
168.067
171.331
174.594
280
Z-3-22-0
183.962
189.481
193.160
196.839
281
Z-3-23-0
191.612
197.361
201.193
205.025
282
Z-3-24-0
376.480
387.775
395.304
402.834
283
Z-3-25-0
167.684
172.714
176.068
179.422
284
Z-3-26-0
189.516
195.201
198.992
202.782
285
Z-3-27-0
PERAWATAN LUKA
180.936
186.364
189.983
193.602
286
Z-3-28-0
IMAGING PAYUDARA
185.730
191.302
195.017
198.731
287
Z-3-29-0
IMAGING LAIN-LAIN
535.308
551.367
562.073
572.779
288
Z-3-30-0
FOTOTERAPI
90.340
93.050
94.857
96.664
- 835 V.
TARIF INA-CBG RUMAH SAKIT UMUM DAN KHUSUS KELAS D

TAHUN 2012
A. RUMAH SAKIT UMUM KELAS D
1. RawatInap
No
Kode
INA-CBG
A-4-10-i
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
SEPTIKEMIA RINGAN
1.092.282
1.102.112
1.108.666
1.115.220
A-4-10-ii
SEPTIKEMIA SEDANG
1.866.808
1.883.609
1.894.810
1.906.011
A-4-10-iii
SEPTIKEMIA BERAT
2.446.316
2.468.333
2.483.011
2.497.688
A-4-11-i
2.930.897
2.957.275
2.974.860
2.992.445
A-4-11-ii

SEDANG
4.527.897
4.568.648
4.595.815
4.622.983
A-4-11-iii
7.406.650
7.473.310
7.517.749
7.562.189
A-4-12-i
DEMAM RINGAN
960.990
969.639
975.404
981.170
A-4-12-ii
DEMAM SEDANG
1.649.053
1.663.894
1.673.788
1.683.683
A-4-12-iii
DEMAM BERAT
1.887.220
1.904.205
1.915.528
1.926.851
10
A-4-13-i
1.201.237
1.212.048
1.219.256
1.226.463
11
A-4-13-ii
1.441.484
1.454.458
1.463.107
1.471.756
12
A-4-13-iii
1.751.954
1.767.721
1.778.233
1.788.745
13
A-4-14-i
1.005.645
1.014.696
1.020.730
1.026.764
14
A-4-14-ii
1.640.206
1.654.967
1.664.809
1.674.650
15
A-4-14-iii
1.830.422
1.846.895
1.857.878
1.868.860
16
A-4-15-i
INFEKSI HIV RINGAN
1.441.484
1.454.458
1.463.107
1.471.756
17
A-4-15-ii
INFEKSI HIV SEDANG
2.162.227
2.181.687
2.194.660
2.207.633
18
A-4-15-iii
INFEKSI HIV BERAT
3.597.788
3.630.168
3.651.755
3.673.342
19
B-1-01-i
15.981.102
16.124.932
16.220.818
16.316.705
20
B-1-01-ii
17.631.428
17.790.111
17.895.899
18.001.688
21
B-1-01-iii
30.929.153
31.207.515
31.393.090
31.578.665
22
B-1-10-i
2.071.896
2.090.543
2.102.974
2.115.405
23
B-1-10-ii
5.280.188
5.327.710
5.359.391
5.391.072
24
B-1-10-iii
10.995.887
11.094.850
11.160.826
11.226.801
25
B-1-11-i
1.694.612
1.709.863
1.720.031
1.730.199
26
B-1-11-ii
4.253.636
4.291.918
4.317.440
4.342.962
27
B-1-11-iii
5.333.003
5.381.000
5.412.998
5.444.996
28
B-1-12-i
3.614.668
3.647.200
3.668.888
3.690.576

LAIN-LAIN RINGAN
LAIN-LAIN SEDANG
LAIN-LAIN BERAT

(RINGAN)
(SEDANG)
(BERAT)
LAPAROSKOPIK RINGAN
- 836 No
Kode
INA-CBG
29
B-1-12-ii
30
B-1-12-iii
31
B-1-13-i
32
B-1-13-ii
33
B-1-13-iii
34
B-1-14-i
35
B-1-14-ii
36
B-1-14-iii
37
B-4-10-i
38
B-4-10-ii
39
B-4-10-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
7.747.118
7.816.842
7.863.325
7.909.807
9.428.534
9.513.391
9.569.962
9.626.534
2.368.612
2.389.929
2.404.141
2.418.352
3.858.124
3.892.848
3.915.996
3.939.145
5.687.958
5.739.150
5.773.277
5.807.405
3.216.408
3.245.355
3.264.654
3.283.952
3.577.295
3.609.490
3.630.954
3.652.418
5.596.252
5.646.618
5.680.196
5.713.773
899.523
907.619
913.016
918.413
1.303.636
1.315.369
1.323.191
1.331.013
2.197.269
2.217.045
2.230.228
2.243.412
2.172.701
2.192.255
2.205.291
2.218.327
3.303.048
3.332.775
3.352.593
3.372.412
3.557.497
3.589.514
3.610.859
3.632.204
1.906.396
1.923.553
1.934.992
1.946.430
2.702.800
2.727.126
2.743.342
2.759.559
5.136.609
5.182.839
5.213.658
5.244.478
1.441.484
1.454.458
1.463.107
1.471.756
1.866.571
1.883.370
1.894.569
1.905.768
3.084.520
3.112.280
3.130.787
3.149.295
1.650.933
1.665.791
1.675.696
1.685.602
1.855.193
1.871.890
1.883.021
1.894.152
2.359.982
2.381.222
2.395.382
2.409.542

LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT
LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT

PANCREAS RINGAN
PANCREAS SEDANG
PANCREAS BERAT
(RINGAN)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT
40
B-4-11-i
41
B-4-11-ii
42
B-4-11-iii
43
B-4-12-i
44
B-4-12-ii
45
B-4-12-iii
46
B-4-13-i
47
B-4-13-ii
48
B-4-13-iii
49
B-4-14-i
50
B-4-14-ii
51
B-4-14-iii
52
C-4-10-i
1.679.422
1.694.536
1.704.613
1.714.689
53
C-4-10-ii
3.262.940
3.292.306
3.311.884
3.331.462
54
C-4-10-iii
LEUKEMIA AKUT BERAT
4.815.300
4.858.638
4.887.529
4.916.421
55
C-4-11-i
1.689.492
1.704.698
1.714.835
1.724.972
56
C-4-11-ii
1.935.853
1.953.275
1.964.891
1.976.506
57
C-4-11-iii
3.909.384
3.944.569
3.968.025
3.991.481
58
C-4-12-i
RADIOTERAPI RINGAN
960.990
969.639
975.404
981.170
59
C-4-12-ii
RADIOTERAPI SEDANG
3.165.580
3.194.071
3.213.064
3.232.058
60
C-4-12-iii
RADIOTERAPI BERAT
6.426.763
6.484.603
6.523.164
6.561.725
- 837 No
Kode
INA-CBG
61
C-4-13-i
62
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
KEMOTERAPI RINGAN
960.990
969.639
975.404
981.170
C-4-13-ii
KEMOTERAPI SEDANG
1.921.979
1.939.277
1.950.809
1.962.341
63
C-4-13-iii
KEMOTERAPI BERAT
2.514.768
2.537.400
2.552.489
2.567.578
64
C-4-14-i
1.490.905
1.504.323
1.513.268
1.522.214
65
C-4-14-ii
2.178.605
2.198.213
2.211.284
2.224.356
66
C-4-14-iii
3.321.221
3.351.112
3.371.039
3.390.966
67
D-1-10-i
10.226.069
10.318.104
10.379.460
10.440.816
68
D-1-10-ii
15.575.088
15.715.263
15.808.714
15.902.164
69
D-1-10-iii
21.108.499
21.298.476
21.425.127
21.551.778
70
D-1-11-i
2.514.716
2.537.348
2.552.436
2.567.525
71
D-1-11-ii
6.472.684
6.530.938
6.569.774
6.608.611
72
D-1-11-iii
9.023.947
9.105.163
9.159.306
9.213.450
73
D-1-20-i
2.589.074
2.612.375
2.627.910
2.643.444
74
D-1-20-ii
6.342.356
6.399.437
6.437.491
6.475.545
75
D-1-20-iii
11.327.197
11.429.142
11.497.105
11.565.068
76
D-4-10-i
990.553
999.467
1.005.411
1.011.354
77
D-4-10-ii
1.863.891
1.880.666
1.891.850
1.903.033
78
D-4-10-iii
2.402.474
2.424.096
2.438.511
2.452.926
79
D-4-11-i
1.201.237
1.212.048
1.219.256
1.226.463
80
D-4-11-ii
2.419.579
2.441.355
2.455.873
2.470.390
81
D-4-11-iii
3.665.325
3.698.313
3.720.305
3.742.297
82
D-4-12-i
1.232.240
1.243.330
1.250.724
1.258.117
83
D-4-12-ii
1.709.238
1.724.621
1.734.876
1.745.132
84
D-4-12-iii
2.624.536
2.648.157
2.663.904
2.679.651
85
D-4-13-i
960.990
969.639
975.404
981.170
86
D-4-13-ii
1.441.484
1.454.458
1.463.107
1.471.756
87
D-4-13-iii
1.771.822
1.787.768
1.798.399
1.809.030
88
D-4-14-i
1.201.237
1.212.048
1.219.256
1.226.463
89
D-4-14-ii
2.703.356
2.727.686
2.743.906
2.760.126
90
D-4-14-iii
3.224.729
3.253.752
3.273.100
3.292.448
91
E-1-01-i
2.756.048
2.780.852
2.797.388
2.813.925
92
E-1-01-ii
3.610.160
3.642.652
3.664.312
3.685.973
93
E-1-01-iii
7.155.938
7.220.342
7.263.277
7.306.213

RINGAN
SEDANG
BERAT
TULANG RINGAN
TULANG SEDANG
TULANG BERAT


RINGAN
SEDANG
BERAT
- 838 No
Kode
INA-CBG
94
E-1-10-i
95
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.347.239
2.368.364
2.382.447
2.396.531
E-1-10-ii
2.848.997
2.874.638
2.891.732
2.908.826
96
E-1-10-iii
6.004.846
6.058.890
6.094.919
6.130.948
97
E-1-20-i
3.252.029
3.281.297
3.300.809
3.320.322
98
E-1-20-ii
4.355.567
4.394.767
4.420.901
4.447.034
99
E-1-20-iii
9.650.706
9.737.563
9.795.467
9.853.371
100
E-4-10-i
1.334.399
1.346.408
1.354.414
1.362.421
101
E-4-10-ii
2.043.965
2.062.360
2.074.624
2.086.888
102
E-4-10-iii
3.466.929
3.498.131
3.518.933
3.539.734
103
E-4-11-i
1.226.211
1.237.246
1.244.604
1.251.961
104
E-4-11-ii
2.319.780
2.340.658
2.354.576
2.368.495
105
E-4-11-iii
3.825.424
3.859.852
3.882.805
3.905.757
106
E-4-12-i
1.321.361
1.333.253
1.341.181
1.349.109
107
E-4-12-ii
2.162.227
2.181.687
2.194.660
2.207.633
108
E-4-12-iii
3.473.874
3.505.139
3.525.982
3.546.825
1.545.447
1.559.356
1.568.628
1.577.901
2.653.543
2.677.425
2.693.346
2.709.267
4.591.299
4.632.621
4.660.169
4.687.716

RINGAN
SEDANG
BERAT

RINGAN
SEDANG
BERAT
109
E-4-13-i
110
E-4-13-ii
111
E-4-13-iii
112
F-4-10-i
SCHIZOFRENIA RINGAN
1.889.601
1.906.607
1.917.945
1.929.283
113
F-4-10-ii
SCHIZOFRENIA SEDANG
2.098.463
2.117.349
2.129.940
2.142.530
114
F-4-10-iii
SCHIZOFRENIA BERAT
3.106.820
3.134.782
3.153.422
3.172.063
115
F-4-11-i
1.741.754
1.757.430
1.767.881
1.778.331
116
F-4-11-ii
2.029.309
2.047.573
2.059.749
2.071.925
117
F-4-11-iii
DEPRESI MAYOR BERAT
2.602.316
2.625.737
2.641.351
2.656.965

IMPULSE RINGAN
IMPULSE SEDANG
IMPULSE BERAT
850.559
858.214
863.318
868.421
1.127.608
1.137.756
1.144.522
1.151.288
2.232.498
2.252.591
2.265.986
2.279.381
118
F-4-12-i
119
F-4-12-ii
120
F-4-12-iii
121
F-4-13-i
1.407.602
1.420.271
1.428.716
1.437.162
122
F-4-13-ii
1.864.027
1.880.803
1.891.987
1.903.172
123
F-4-13-iii
2.403.425
2.425.056
2.439.476
2.453.897
124
F-4-14-i
DEPRESI RINGAN
985.322
994.190
1.000.101
1.006.013
125
F-4-14-ii
DEPRESI SEDANG
1.263.875
1.275.250
1.282.833
1.290.416
126
F-4-14-iii
DEPRESI BERAT
1.700.600
1.715.905
1.726.109
1.736.312
- 839 No
Kode
INA-CBG
127
F-4-15-i
128
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.171.491
1.182.035
1.189.064
1.196.092
F-4-15-ii
1.649.217
1.664.060
1.673.955
1.683.851
129
F-4-15-iii
2.059.827
2.078.365
2.090.724
2.103.083
130
F-4-16-i
2.523.163
2.545.871
2.561.010
2.576.149
131
F-4-16-ii
2.933.114
2.959.512
2.977.110
2.994.709
132
F-4-16-iii
3.915.217
3.950.454
3.973.945
3.997.437
133
F-4-17-i
486.930
491.312
494.233
497.155
134
F-4-17-ii
1.427.144
1.439.988
1.448.551
1.457.114
135
F-4-17-iii
1.522.658
1.536.362
1.545.498
1.554.634
136
F-4-18-i
2.186.992
2.206.675
2.219.797
2.232.919
137
F-4-18-ii
2.406.309
2.427.966
2.442.404
2.456.842
138
F-4-18-iii
3.709.536
3.742.922
3.765.179
3.787.436
139
F-4-19-i
1.677.217
1.692.312
1.702.375
1.712.438
140
F-4-19-ii
2.147.719
2.167.049
2.179.935
2.192.822
141
F-4-19-iii
2.673.939
2.698.005
2.714.048
2.730.092
142
G-1-01-i
4.456.851
4.496.962
4.523.703
4.550.444
143
G-1-01-ii
7.543.757
7.611.650
7.656.913
7.702.175
144
G-1-01-iii
14.603.870
14.735.305
14.822.928
14.910.552
145
G-1-10-i
2.661.052
2.685.001
2.700.968
2.716.934
146
G-1-10-ii
3.756.744
3.790.554
3.813.095
3.835.635
147
G-1-10-iii
4.452.544
4.492.617
4.519.332
4.546.047
148
G-1-11-i
3.069.603
3.097.229
3.115.647
3.134.065
149
G-1-11-ii
6.303.661
6.360.394
6.398.216
6.436.038
150
G-1-11-iii
12.945.368
13.061.877
13.139.549
13.217.221
151
G-1-12-i
2.387.247
2.408.732
2.423.055
2.437.379
152
G-1-12-ii
5.465.363
5.514.552
5.547.344
5.580.136
153
G-1-12-iii
8.613.224
8.690.743
8.742.422
8.794.102
154
G-1-13-i
526.233
530.969
534.126
537.284
155
G-1-13-ii
1.413.403
1.426.124
1.434.605
1.443.085
156
G-1-13-iii
3.189.234
3.217.937
3.237.072
3.256.207
157
G-1-20-i
3.008.134
3.035.207
3.053.256
3.071.305
158
G-1-20-ii
4.064.087
4.100.664
4.125.049
4.149.433
159
G-1-20-iii
9.950.440
10.039.994
10.099.696
10.159.399

RINGAN
SEDANG
BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

RINGAN
SEDANG
BERAT
- 840 No
Kode
INA-CBG
160
G-1-30-i
161
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.836.604
3.871.133
3.894.153
3.917.173
G-1-30-ii
10.013.904
10.104.029
10.164.112
10.224.196
162
G-1-30-iii
12.890.989
13.007.008
13.084.354
13.161.700
163
G-4-10-i
1.441.484
1.454.458
1.463.107
1.471.756
164
G-4-10-ii
1.753.401
1.769.182
1.779.702
1.790.222
165
G-4-10-iii
3.073.846
3.101.511
3.119.954
3.138.397
166
G-4-11-i
2.845.482
2.871.091
2.888.164
2.905.237
167
G-4-11-ii
3.300.759
3.330.466
3.350.271
3.370.075
168
G-4-11-iii
4.837.320
4.880.855
4.909.879
4.938.903
169
G-4-12-i
2.128.170
2.147.324
2.160.093
2.172.862
170
G-4-12-ii
2.681.494
2.705.628
2.721.717
2.737.806
171
G-4-12-iii
3.894.551
3.929.602
3.952.970
3.976.337
172
G-4-13-i
1.184.100
1.194.757
1.201.861
1.208.966
173
G-4-13-ii
1.681.732
1.696.867
1.706.958
1.717.048
174
G-4-13-iii
1.988.046
2.005.938
2.017.866
2.029.795
175
G-4-14-i
2.165.542
2.185.032
2.198.025
2.211.018
176
G-4-14-ii
3.563.047
3.595.114
3.616.493
3.637.871
177
G-4-14-iii
4.461.016
4.501.165
4.527.931
4.554.697
178
G-4-15-i
1.441.484
1.454.458
1.463.107
1.471.756
179
G-4-15-ii
1.827.478
1.843.925
1.854.890
1.865.855
180
G-4-15-iii
2.766.313
2.791.210
2.807.808
2.824.405
181
G-4-16-i
1.201.237
1.212.048
1.219.256
1.226.463
182
G-4-16-ii
1.796.461
1.812.629
1.823.408
1.834.186
183
G-4-16-iii
3.260.255
3.289.598
3.309.159
3.328.721
184
G-4-17-i
2.053.854
2.072.339
2.084.662
2.096.985
185
G-4-17-ii
2.548.923
2.571.863
2.587.157
2.602.450
186
G-4-17-iii
4.272.016
4.310.464
4.336.096
4.361.728
187
G-4-18-i
1.441.484
1.454.458
1.463.107
1.471.756
188
G-4-18-ii
2.472.792
2.495.047
2.509.883
2.524.720
189
G-4-18-iii
2.619.671
2.643.248
2.658.966
2.674.684

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
DEGENERATIF RINGAN
DEGENERATIF SEDANG
DEGENERATIF BERAT
RINGAN
SEDANG
BERAT
TRAUMATIK RINGAN
TRAUMATIK SEDANG
TRAUMATIK BERAT
DENGAN INFARK BERAT
TANPA INFARK RINGAN
TANPA INFARK SEDANG
TANPA INFARK BERAT

PERIFER RINGAN
PERIFER SEDANG
PERIFER BERAT
PERSARAFAN RINGAN
PERSARAFAN SEDANG
PERSARAFAN BERAT
- 841 No
Kode
INA-CBG
190
G-4-19-i
191
G-4-19-ii
192
G-4-19-iii
193
G-4-20-i
194
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.436.407
1.449.335
1.457.953
1.466.572
2.544.358
2.567.257
2.582.524
2.597.790
3.631.454
3.664.137
3.685.926
3.707.714
840.866
848.434
853.479
858.524
G-4-20-ii
1.194.030
1.204.777
1.211.941
1.219.105
195
G-4-20-iii
2.036.102
2.054.427
2.066.643
2.078.860
196
G-4-21-i
1.165.750
1.176.241
1.183.236
1.190.230
197
G-4-21-ii
1.620.369
1.634.953
1.644.675
1.654.397
198
G-4-21-iii
2.844.429
2.870.029
2.887.096
2.904.162
199
G-4-22-i
960.990
969.639
975.404
981.170
200
G-4-22-ii
1.201.237
1.212.048
1.219.256
1.226.463
201
G-4-22-iii
1.378.133
1.390.536
1.398.805
1.407.074
202
G-4-23-i
1.051.348
1.060.810
1.067.119
1.073.427
203
G-4-23-ii
1.201.237
1.212.048
1.219.256
1.226.463
204
G-4-23-iii
1.717.083
1.732.537
1.742.839
1.753.142
205
G-4-24-i
960.990
969.639
975.404
981.170
206
G-4-24-ii
1.275.963
1.287.447
1.295.103
1.302.758
207
G-4-24-iii
TRAUMA KEPALA BERAT
2.524.270
2.546.988
2.562.134
2.577.279
208
G-4-25-i
GEGAR OTAK RINGAN
960.990
969.639
975.404
981.170
209
G-4-25-ii
GEGAR OTAK SEDANG
1.201.237
1.212.048
1.219.256
1.226.463
210
G-4-25-iii
GEGAR OTAK BERAT
1.499.973
1.513.472
1.522.472
1.531.472
1.724.610
1.740.131
1.750.479
1.760.826
1.964.893
1.982.577
1.994.366
2.006.156
3.210.191
3.239.082
3.258.344
3.277.605

RINGAN
SEDANG

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
211
G-4-26-i
212
G-4-26-ii
213
G-4-26-iii
214
H-1-20-i
1.652.626
1.667.500
1.677.416
1.687.331
215
H-1-20-ii
3.013.751
3.040.875
3.058.957
3.077.040
216
H-1-20-iii
4.098.513
4.135.400
4.159.991
4.184.582
1.618.078
1.632.641
1.642.350
1.652.058
1.844.609
1.861.211
1.872.279
1.883.346

RINGAN
SEDANG
217
H-1-30-i
218
H-1-30-ii
219
H-1-30-iii
3.077.664
3.105.363
3.123.829
3.142.295
220
H-4-10-i
1.465.708
1.478.899
1.487.694
1.496.488
221
H-4-10-ii
2.402.474
2.424.096
2.438.511
2.452.926
- 842 No
Kode
INA-CBG
222
H-4-10-iii
223
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.916.742
3.951.993
3.975.493
3.998.994
H-4-11-i
1.174.270
1.184.838
1.191.884
1.198.929
224
H-4-11-ii
1.296.168
1.307.834
1.315.611
1.323.388
225
H-4-11-iii
1.719.740
1.735.217
1.745.536
1.755.854
226
H-4-12-i
1.629.252
1.643.915
1.653.691
1.663.466
227
H-4-12-ii
2.206.929
2.226.791
2.240.032
2.253.274
228
H-4-12-iii
3.682.110
3.715.249
3.737.341
3.759.434
229
I-1-01-i
20.732.199
20.918.789
21.043.182
21.167.575
230
I-1-01-ii
21.188.416
21.379.111
21.506.242
21.633.372
231
I-1-01-iii
33.445.508
33.746.517
33.947.190
34.147.863
232
I-1-02-i
11.502.105
11.605.624
11.674.636
11.743.649
233
I-1-02-ii
14.837.715
14.971.254
15.060.281
15.149.307
234
I-1-02-iii
18.288.346
18.452.942
18.562.672
18.672.402
235
I-1-03-i
7.083.405
7.147.156
7.189.656
7.232.157
236
I-1-03-ii
9.709.026
9.796.408
9.854.662
9.912.916
237
I-1-03-iii
14.239.905
14.368.064
14.453.504
14.538.943
238
I-1-04-i
10.338.852
10.431.902
10.493.935
10.555.968
239
I-1-04-ii
13.280.439
13.399.963
13.479.646
13.559.328
240
I-1-04-iii
28.311.139
28.565.939
28.735.806
28.905.673
241
I-1-05-i
15.223.374
15.360.384
15.451.724
15.543.065
242
I-1-05-ii
18.268.049
18.432.461
18.542.069
18.651.678
243
I-1-05-iii
25.136.720
25.362.950
25.513.770
25.664.591
244
I-1-06-i
8.585.407
8.662.676
8.714.188
8.765.701
245
I-1-06-ii
12.624.523
12.738.144
12.813.891
12.889.638
246
I-1-06-iii
13.942.376
14.067.857
14.151.511
14.235.166
247
I-1-07-i
11.290.460
11.392.074
11.459.817
11.527.560
248
I-1-07-ii
13.929.076
14.054.438
14.138.013
14.221.587
249
I-1-07-iii
15.196.532
15.333.301
15.424.480
15.515.659
250
I-1-11-i
2.147.721
2.167.050
2.179.937
2.192.823
251
I-1-11-ii
2.388.051
2.409.543
2.423.872
2.438.200

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
KATETERISASI RINGAN
KATETERISASI SEDANG
KATETERISASI BERAT
RINGAN
SEDANG
BERAT

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
RINGAN
SEDANG
- 843 No
Kode
INA-CBG
252
I-1-11-iii
253
I-1-12-i
254
I-1-12-ii
255
I-1-12-iii
256
I-1-13-i
257
I-1-13-ii
258
I-1-13-iii
259
I-1-14-i
260
I-1-14-ii
261
I-1-14-iii
262
I-1-15-i
263
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.177.768
3.206.368
3.225.434
3.244.501
5.501.782
5.551.298
5.584.308
5.617.319
7.633.979
7.702.685
7.748.488
7.794.292
10.647.598
10.743.427
10.807.312
10.871.198
3.353.587
3.383.770
3.403.891
3.424.013
3.765.286
3.799.173
3.821.765
3.844.357
8.212.011
8.285.919
8.335.191
8.384.463
11.840.402
11.946.965
12.018.008
12.089.050
14.715.928
14.848.371
14.936.667
15.024.963
19.282.940
19.456.487
19.572.184
19.687.882
2.775.857
2.800.840
2.817.495
2.834.150
I-1-15-ii
6.796.318
6.857.485
6.898.263
6.939.041
264
I-1-15-iii
9.938.721
10.028.169
10.087.802
10.147.434
265
I-1-16-i
5.074.458
5.120.128
5.150.575
5.181.022
266
I-1-16-ii
13.193.591
13.312.333
13.391.495
13.470.656
267
I-1-16-iii
15.218.483
15.355.449
15.446.760
15.538.071
268
I-1-17-i
1.947.064
1.964.588
1.976.270
1.987.953
269
I-1-17-ii
4.033.076
4.069.374
4.093.573
4.117.771
270
I-1-17-iii
23.381.324
23.591.756
23.732.044
23.872.332
271
I-1-20-i
2.880.344
2.906.268
2.923.550
2.940.832
272
I-1-20-ii
4.776.841
4.819.832
4.848.494
4.877.155
273
I-1-20-iii
8.347.802
8.422.933
8.473.019
8.523.106
274
I-1-30-i
5.756.999
5.808.812
5.843.354
5.877.896
275
I-1-30-ii
11.975.721
12.083.502
12.155.357
12.227.211
276
I-1-30-iii
18.558.018
18.725.040
18.836.388
18.947.736
277
I-1-40-i
9.262.463
9.345.825
9.401.399
9.456.974
278
I-1-40-ii
7.012.276
7.075.387
7.117.460
7.159.534
279
I-1-40-iii
11.537.033
11.640.867
11.710.089
11.779.311

BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

DARAH VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
- 844 No
Kode
INA-CBG
280
I-4-10-i
281
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.693.793
2.718.037
2.734.200
2.750.363
I-4-10-ii
4.253.548
4.291.830
4.317.351
4.342.872
282
I-4-10-iii
6.136.114
6.191.339
6.228.156
6.264.972
283
I-4-11-i
3.097.072
3.124.945
3.143.528
3.162.110
284
I-4-11-ii
3.603.711
3.636.144
3.657.767
3.679.389
285
I-4-11-iii
5.847.012
5.899.635
5.934.717
5.969.799
286
I-4-12-i
2.797.730
2.822.909
2.839.696
2.856.482
287
I-4-12-ii
3.992.352
4.028.283
4.052.238
4.076.192
288
I-4-12-iii
4.843.285
4.886.875
4.915.934
4.944.994
2.513.130
2.535.749
2.550.827
2.565.906
3.651.066
3.683.925
3.705.832
3.727.738
6.246.432
6.302.650
6.340.129
6.377.607

VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
289
I-4-13-i
290
I-4-13-ii
291
I-4-13-iii
292
I-4-14-i
1.562.935
1.577.001
1.586.379
1.595.757
293
I-4-14-ii
1.828.865
1.845.325
1.856.298
1.867.271
294
I-4-14-iii
2.834.132
2.859.640
2.876.644
2.893.649
1.921.979
1.939.277
1.950.809
1.962.341
3.291.819
3.321.445
3.341.196
3.360.947
3.751.881
3.785.648
3.808.159
3.830.671

295
I-4-15-i
296
I-4-15-ii
297
I-4-15-iii
298
I-4-16-i
1.441.484
1.454.458
1.463.107
1.471.756
299
I-4-16-ii
2.336.150
2.357.175
2.371.192
2.385.209
300
I-4-16-iii
2.943.134
2.969.622
2.987.281
3.004.940
301
I-4-17-i
HIPERTENSI RINGAN
1.543.490
1.557.381
1.566.642
1.575.903
302
I-4-17-ii
HIPERTENSI SEDANG
2.105.601
2.124.551
2.137.185
2.149.819
303
I-4-17-iii
HIPERTENSI BERAT
2.461.025
2.483.174
2.497.940
2.512.706
2.273.117
2.293.575
2.307.214
2.320.853
3.482.263
3.513.604
3.534.497
3.555.391
4.694.649
4.736.901
4.765.069
4.793.237
1.779.012
1.795.023
1.805.697
1.816.371
2.887.968
2.913.960
2.931.288
2.948.616
3.308.076
3.337.848
3.357.697
3.377.545

RINGAN
SEDANG
KONGENITAL BERAT
RINGAN
SEDANG
BERAT
304
I-4-18-i
305
I-4-18-ii
306
I-4-18-iii
307
I-4-19-i
308
I-4-19-ii
309
I-4-19-iii
310
I-4-20-i
2.159.083
2.178.515
2.191.469
2.204.424
311
I-4-20-ii
2.487.425
2.509.812
2.524.736
2.539.661
312
I-4-20-iii
3.301.227
3.330.938
3.350.745
3.370.553
- 845 No
Kode
INA-CBG
313
I-4-21-i
314
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.871.231
2.897.072
2.914.300
2.931.527
I-4-21-ii
3.581.675
3.613.910
3.635.400
3.656.890
315
I-4-21-iii
4.886.164
4.930.139
4.959.456
4.988.773
316
I-4-22-i
1.561.608
1.575.663
1.585.032
1.594.402
317
I-4-22-ii
1.799.440
1.815.635
1.826.432
1.837.228
318
I-4-22-iii
2.625.334
2.648.962
2.664.714
2.680.466
1.183.006
1.193.653
1.200.751
1.207.849
1.452.459
1.465.531
1.474.246
1.482.961
2.837.972
2.863.514
2.880.542
2.897.570
1.688.119
1.703.312
1.713.441
1.723.570
4.214.767
4.252.700
4.277.989
4.303.277
5.328.812
5.376.771
5.408.744
5.440.717
13.600.659
13.723.065
13.804.669
13.886.273
14.529.535
14.660.301
14.747.478
14.834.655
24.823.796
25.047.210
25.196.153
25.345.096
6.952.387
7.014.959
7.056.673
7.098.388
7.447.859
7.514.890
7.559.577
7.604.264
11.005.814
11.104.866
11.170.901
11.236.936
2.712.922
2.737.338
2.753.616
2.769.893
6.552.693
6.611.667
6.650.983
6.690.299
11.139.604
11.239.860
11.306.698
11.373.536
2.344.833
2.365.936
2.380.005
2.394.074
3.410.374
3.441.067
3.461.530
3.481.992
5.030.817
5.076.094
5.106.279
5.136.464
1.581.250
1.595.481
1.604.969
1.614.456
6.785.759
6.846.830
6.887.545
6.928.260
19.521.331
19.697.023
19.814.151
19.931.279

RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
319
I-4-23-i
320
I-4-23-ii
321
I-4-23-iii
322
I-4-24-i
323
I-4-24-ii
324
I-4-24-iii
325
J-1-01-i
326
J-1-01-ii
327
J-1-01-iii
328
J-1-02-i
329
J-1-02-ii
330
J-1-02-iii
331
J-1-10-i
332
J-1-10-ii
333
J-1-10-iii
334
J-1-20-i
335
J-1-20-ii
336
J-1-20-iii
337
J-1-30-i
338
J-1-30-ii
339
J-1-30-iii
340
J-4-10-i
1.525.372
1.539.100
1.548.253
1.557.405
341
J-4-10-ii
2.181.099
2.200.729
2.213.815
2.226.902
342
J-4-10-iii
3.299.677
3.329.374
3.349.172
3.368.970
343
J-4-11-i
1.151.326
1.161.688
1.168.596
1.175.504
- 846 No
Kode
INA-CBG
344
J-4-11-ii
345
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.602.620
1.617.044
1.626.659
1.636.275
J-4-11-iii
2.296.595
2.317.265
2.331.044
2.344.824
346
J-4-12-i
EMBOLI PARU RINGAN
1.471.631
1.484.875
1.493.705
1.502.535
347
J-4-12-ii
EMBOLI PARU SEDANG
1.905.711
1.922.863
1.934.297
1.945.731
348
J-4-12-iii
EMBOLI PARU BERAT
2.544.885
2.567.789
2.583.058
2.598.328
349
J-4-13-i
2.712.111
2.736.520
2.752.793
2.769.065
350
J-4-13-ii
3.986.803
4.022.685
4.046.605
4.070.526
351
J-4-13-iii
6.481.945
6.540.283
6.579.175
6.618.066
352
J-4-14-i
TUMOR PARU RINGAN
1.848.218
1.864.852
1.875.941
1.887.031
353
J-4-14-ii
TUMOR PARU SEDANG
3.096.018
3.123.882
3.142.458
3.161.034
354
J-4-14-iii
TUMOR PARU BERAT
3.681.008
3.714.137
3.736.223
3.758.309
355
J-4-15-i
1.618.045
1.632.607
1.642.315
1.652.023
356
J-4-15-ii
2.278.303
2.298.808
2.312.477
2.326.147
357
J-4-15-iii
2.862.979
2.888.746
2.905.924
2.923.102
358
J-4-16-i
1.201.237
1.212.048
1.219.256
1.226.463
359
J-4-16-ii
1.902.154
1.919.274
1.930.687
1.942.100
360
J-4-16-iii
3.116.751
3.144.802
3.163.502
3.182.203
361
J-4-17-i
1.324.683
1.336.605
1.344.553
1.352.501
362
J-4-17-ii
1.797.979
1.814.161
1.824.949
1.835.737
363
J-4-17-iii
2.883.803
2.909.757
2.927.060
2.944.363
364
J-4-18-i
960.990
969.639
975.404
981.170
365
J-4-18-ii
1.373.613
1.385.976
1.394.218
1.402.459
366
J-4-18-iii
1.436.458
1.449.387
1.458.005
1.466.624
367
J-4-19-i
1.681.732
1.696.867
1.706.958
1.717.048
368
J-4-19-ii
2.278.286
2.298.791
2.312.460
2.326.130
369
J-4-19-iii
3.256.682
3.285.992
3.305.532
3.325.072
370
J-4-20-i
1.853.076
1.869.754
1.880.872
1.891.991
371
J-4-20-ii
2.454.322
2.476.411
2.491.137
2.505.863
372
J-4-20-iii
4.892.121
4.936.150
4.965.503
4.994.856
373
J-4-21-i
1.031.464
1.040.748
1.046.936
1.053.125
374
J-4-21-ii
2.370.937
2.392.275
2.406.501
2.420.726
375
J-4-21-iii
3.381.731
3.412.167
3.432.457
3.452.748
376
K-1-10-i
2.589.074
2.612.375
2.627.910
2.643.444

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT

USUS BESAR (RINGAN)
- 847 No
Kode
INA-CBG
377
K-1-10-ii
378
K-1-10-iii
379
K-1-11-i
380
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.322.903
4.361.809
4.387.747
4.413.684
5.062.864
5.108.430
5.138.807
5.169.184
2.663.459
2.687.430
2.703.411
2.719.392
K-1-11-ii
3.496.800
3.528.271
3.549.252
3.570.233
381
K-1-11-iii
8.874.191
8.954.058
9.007.304
9.060.549
382
K-1-12-i
1.432.737
1.445.632
1.454.228
1.462.825
383
K-1-12-ii
1.867.300
1.884.105
1.895.309
1.906.513
384
K-1-12-iii
3.714.452
3.747.882
3.770.168
3.792.455
385
K-1-13-i
1.627.393
1.642.040
1.651.804
1.661.568
386
K-1-13-ii
2.842.588
2.868.171
2.885.227
2.902.282
387
K-1-13-iii
3.040.045
3.067.406
3.085.646
3.103.886
388
K-1-14-i
2.629.963
2.653.633
2.669.413
2.685.193
389
K-1-14-ii
3.089.190
3.116.993
3.135.528
3.154.063
390
K-1-14-iii
7.606.481
7.674.940
7.720.578
7.766.217
391
K-1-20-i
5.102.900
5.148.826
5.179.444
5.210.061
392
K-1-20-ii
7.122.303
7.186.404
7.229.138
7.271.872
393
K-1-20-iii
15.213.576
15.350.498
15.441.780
15.533.061
394
K-1-30-i
3.358.983
3.389.214
3.409.368
3.429.522
395
K-1-30-ii
5.178.147
5.224.751
5.255.820
5.286.888
396
K-1-30-iii
9.648.227
9.735.061
9.792.951
9.850.840
397
K-1-40-i
3.374.504
3.404.874
3.425.121
3.445.368
398
K-1-40-ii
3.713.306
3.746.726
3.769.006
3.791.286
399
K-1-40-iii
6.158.161
6.213.584
6.250.533
6.287.482
400
K-1-50-i
2.573.932
2.597.098
2.612.541
2.627.985
401
K-1-50-ii
3.333.364
3.363.364
3.383.364
3.403.364
402
K-1-50-iii
PROSEDUR ANAL BERAT
4.732.490
4.775.082
4.803.477
4.831.872
403
K-4-10-i
1.949.569
1.967.115
1.978.812
1.990.509
404
K-4-10-ii
2.332.773
2.353.768
2.367.765
2.381.762
405
K-4-10-iii
8.074.127
8.146.794
8.195.239
8.243.684
406
K-4-11-i
960.990
969.639
975.404
981.170
407
K-4-11-ii
1.563.093
1.577.161
1.586.540
1.595.918
408
K-4-11-iii
2.619.696
2.643.274
2.658.992
2.674.710
409
K-4-12-i
983.351
992.201
998.101
1.004.001

USUS BESAR (SEDANG)
USUS BESAR (BERAT)


RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
- 848 No
Kode
INA-CBG
410
K-4-12-ii
411
K-4-12-iii
412
K-4-13-i
413
K-4-13-ii
414
K-4-13-iii
415
K-4-14-i
416
K-4-14-ii
417
K-4-14-iii
418
K-4-15-i
419
K-4-15-ii
420
K-4-15-iii
421
K-4-16-i
422
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.717.693
1.733.152
1.743.459
1.753.765
4.122.341
4.159.442
4.184.176
4.208.911
1.441.484
1.454.458
1.463.107
1.471.756
1.867.077
1.883.881
1.895.083
1.906.286
3.053.721
3.081.205
3.099.527
3.117.849
1.201.237
1.212.048
1.219.256
1.226.463
1.625.749
1.640.381
1.650.135
1.659.890
2.625.527
2.649.156
2.664.910
2.680.663
1.201.237
1.212.048
1.219.256
1.226.463
2.258.653
2.278.981
2.292.533
2.306.085
3.213.657
3.242.580
3.261.862
3.281.144
1.201.237
1.212.048
1.219.256
1.226.463
K-4-16-ii
1.566.445
1.580.543
1.589.942
1.599.341
423
K-4-16-iii
2.105.110
2.124.056
2.136.687
2.149.317
424
K-4-17-i
960.990
969.639
975.404
981.170
425
K-4-17-ii
1.677.492
1.692.589
1.702.654
1.712.719
426
K-4-17-iii
2.232.570
2.252.663
2.266.059
2.279.454
427
K-4-18-i
1.145.995
1.156.309
1.163.185
1.170.061
428
K-4-18-ii
1.784.873
1.800.937
1.811.646
1.822.355
429
K-4-18-iii
2.075.395
2.094.073
2.106.525
2.118.978
430
L-1-20-i
11.765.575
11.871.465
11.942.059
12.012.652
431
L-1-20-ii
12.161.648
12.271.103
12.344.073
12.417.043
432
L-1-20-iii
20.634.464
20.820.174
20.943.981
21.067.788
433
L-1-30-i
4.530.879
4.571.657
4.598.842
4.626.027
434
L-1-30-ii
7.729.964
7.799.534
7.845.914
7.892.293
435
L-1-30-iii
8.152.700
8.226.075
8.274.991
8.323.907
436
L-1-40-i
2.154.731
2.174.123
2.187.052
2.199.980
437
L-1-40-ii
4.849.653
4.893.299
4.922.397
4.951.495
438
L-1-40-iii
7.428.266
7.495.120
7.539.690
7.584.260
439
L-1-50-i
3.236.342
3.265.469
3.284.887
3.304.305
440
L-1-50-ii
5.825.416
5.877.845
5.912.797
5.947.749

(RINGAN)
(SEDANG)
RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
- 849 No
Kode
INA-CBG
441
L-1-50-iii
442
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
7.043.752
7.107.146
7.149.408
7.191.671
L-4-10-i
1.441.484
1.454.458
1.463.107
1.471.756
443
L-4-10-ii
1.977.637
1.995.436
2.007.302
2.019.167
444
L-4-10-iii
4.070.194
4.106.826
4.131.247
4.155.668
445
L-4-11-i
1.631.167
1.645.847
1.655.634
1.665.421
446
L-4-11-ii
2.234.670
2.254.782
2.268.190
2.281.598
447
L-4-11-iii
6.060.144
6.114.686
6.151.047
6.187.407
448
L-4-12-i
1.610.249
1.624.741
1.634.402
1.644.064
449
L-4-12-ii
2.530.402
2.553.176
2.568.358
2.583.541
450
L-4-12-iii
4.097.896
4.134.777
4.159.364
4.183.952
451
L-4-13-i
1.082.485
1.092.228
1.098.723
1.105.218
452
L-4-13-ii
1.248.169
1.259.403
1.266.892
1.274.381
453
L-4-13-iii
1.872.352
1.889.203
1.900.437
1.911.671
454
L-4-14-i
986.472
995.350
1.001.269
1.007.188
455
L-4-14-ii
1.466.151
1.479.347
1.488.143
1.496.940
456
L-4-14-iii
2.696.458
2.720.726
2.736.905
2.753.084
457
M-1-01-i
4.685.199
4.727.365
4.755.477
4.783.588
458
M-1-01-ii
5.229.440
5.276.505
5.307.881
5.339.258
459
M-1-01-iii
7.345.946
7.412.059
7.456.135
7.500.211
460
M-1-02-i
3.970.073
4.005.804
4.029.624
4.053.445
461
M-1-02-ii
6.518.106
6.576.769
6.615.877
6.654.986
462
M-1-02-iii
11.803.990
11.910.226
11.981.050
12.051.874
463
M-1-03-i
8.414.489
8.490.220
8.540.707
8.591.194
464
M-1-03-ii
9.847.413
9.936.040
9.995.125
10.054.209
465
M-1-03-iii
11.398.705
11.501.293
11.569.686
11.638.078
466
M-1-04-i
2.618.938
2.642.509
2.658.222
2.673.936
467
M-1-04-ii
3.357.452
3.387.669
3.407.814
3.427.958
468
M-1-04-iii
4.201.218
4.239.029
4.264.236
4.289.444
469
M-1-05-i
4.079.803
4.116.521
4.141.000
4.165.479
470
M-1-05-ii
4.715.159
4.757.595
4.785.886
4.814.177
471
M-1-05-iii
8.031.200
8.103.481
8.151.668
8.199.855
472
M-1-07-i
3.764.197
3.798.075
3.820.660
3.843.245


- 850 No
Kode
INA-CBG
473
M-1-07-ii
474
M-1-07-iii
475
M-1-10-i
476
M-1-10-ii
477
M-1-10-iii
478
M-1-20-i
479
M-1-20-ii
480
M-1-20-iii
481
M-1-30-i
482
M-1-30-ii
483
M-1-30-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.042.848
5.088.234
5.118.491
5.148.748
10.272.759
10.365.214
10.426.851
10.488.487
2.814.621
2.839.952
2.856.840
2.873.728
10.455.040
10.549.135
10.611.866
10.674.596
12.405.427
12.517.076
12.591.508
12.665.941
2.784.387
2.809.446
2.826.153
2.842.859
3.154.335
3.182.724
3.201.650
3.220.576
7.725.489
7.795.018
7.841.371
7.887.724
1.665.480
1.680.469
1.690.462
1.700.455
3.441.305
3.472.276
3.492.924
3.513.572
PROSEDUR KAKI BERAT
5.133.701
5.179.904
5.210.706
5.241.509
1.644.662
1.659.464
1.669.332
1.679.200
2.707.038
2.731.402
2.747.644
2.763.886
4.530.879
4.571.657
4.598.842
4.626.027

TULANG WAJAH RINGAN
TULANG WAJAH SEDANG
TULANG WAJAH BERAT

RINGAN
SEDANG
BERAT
484
M-1-40-i
485
M-1-40-ii
486
M-1-40-iii
487
M-1-50-i
2.228.707
2.248.765
2.262.137
2.275.509
488
M-1-50-ii
4.486.439
4.526.817
4.553.735
4.580.654
489
M-1-50-iii
5.178.147
5.224.751
5.255.820
5.286.888
490
M-1-60-i
1.681.970
1.697.108
1.707.200
1.717.292
491
M-1-60-ii
3.367.315
3.397.621
3.417.825
3.438.029
492
M-1-60-iii
5.860.320
5.913.063
5.948.225
5.983.387
493
M-1-70-i
2.253.164
2.273.442
2.286.961
2.300.480
494
M-1-70-ii
4.597.570
4.638.948
4.666.534
4.694.119
495
M-1-70-iii
7.411.838
7.478.545
7.523.016
7.567.487
496
M-1-80-i
1.815.440
1.831.779
1.842.672
1.853.564
497
M-1-80-ii
2.744.574
2.769.276
2.785.743
2.802.210
498
M-1-80-iii
6.318.721
6.375.590
6.413.502
6.451.414
499
M-4-10-i
977.694
986.493
992.359
998.225
500
M-4-10-ii
1.754.214
1.770.002
1.780.527
1.791.053
501
M-4-10-iii
FRAKTUR FEMUR BERAT
3.724.981
3.758.506
3.780.855
3.803.205
1.521.622
1.535.317
1.544.446
1.553.576
3.490.827
3.522.245
3.543.190
3.564.135
502
M-4-11-i
503
M-4-11-ii

SELAIN KAKI (BERAT)

PANGGUL RINGAN
PANGGUL SEDANG
- 851 No
Kode
INA-CBG
504
M-4-11-iii
505
M-4-12-i
506
M-4-12-ii
507
M-4-12-iii
508
M-4-13-i
509
M-4-13-ii
510
M-4-13-iii
511
M-4-14-i
512
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
6.196.137
6.251.902
6.289.079
6.326.256
960.990
969.639
975.404
981.170
1.748.519
1.764.256
1.774.747
1.785.238
3.843.958
3.878.554
3.901.618
3.924.682
2.122.521
2.141.624
2.154.359
2.167.094
2.402.474
2.424.096
2.438.511
2.452.926
6.313.968
6.370.794
6.408.678
6.446.561
1.921.979
1.939.277
1.950.809
1.962.341
M-4-14-ii
2.985.341
3.012.209
3.030.121
3.048.033
513
M-4-14-iii
OSTEOMIELITIS BERAT
4.356.132
4.395.338
4.421.474
4.447.611
514
M-4-15-i
1.434.629
1.447.541
1.456.149
1.464.756
515
M-4-15-ii
1.912.960
1.930.176
1.941.654
1.953.132
516
M-4-15-iii
4.084.206
4.120.964
4.145.469
4.169.974
517
M-4-16-i
1.433.243
1.446.142
1.454.742
1.463.341
518
M-4-16-ii
2.094.416
2.113.266
2.125.833
2.138.399
519
M-4-16-iii
4.275.717
4.314.199
4.339.853
4.365.508
520
M-4-17-i
1.227.917
1.238.968
1.246.336
1.253.703
521
M-4-17-ii
1.681.732
1.696.867
1.706.958
1.717.048
522
M-4-17-iii
2.348.628
2.369.765
2.383.857
2.397.949
523
M-4-18-i
1.684.592
1.699.753
1.709.861
1.719.968
524
M-4-18-ii
2.074.530
2.093.201
2.105.648
2.118.095
525
M-4-18-iii
2.856.969
2.882.682
2.899.824
2.916.966
526
M-4-19-i
1.252.517
1.263.789
1.271.305
1.278.820
527
M-4-19-ii
2.109.639
2.128.626
2.141.284
2.153.942
528
M-4-19-iii
3.596.952
3.629.325
3.650.906
3.672.488
529
M-4-20-i
960.990
969.639
975.404
981.170
530
M-4-20-ii
1.441.484
1.454.458
1.463.107
1.471.756
531
M-4-20-iii
1.597.504
1.611.882
1.621.467
1.631.052
532
M-4-21-i
960.990
969.639
975.404
981.170
533
M-4-21-ii
1.500.699
1.514.206
1.523.210
1.532.214

PANGGUL BERAT
PELVIS RINGAN
PELVIS SEDANG
PELVIS BERAT

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
RINGAN
SEDANG
BERAT
ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
- 852 No
Kode
INA-CBG
534
M-4-21-iii
535
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

3.483.587
3.514.940
3.535.841
3.556.743
N-1-01-i
2.600.178
2.623.579
2.639.181
2.654.782
536
N-1-01-ii
3.516.682
3.548.332
3.569.432
3.590.532
537
N-1-01-iii
7.456.412
7.523.519
7.568.258
7.612.996
538
N-1-11-i
4.291.705
4.330.331
4.356.081
4.381.831
539
N-1-11-ii
5.804.435
5.856.675
5.891.501
5.926.328
540
N-1-11-iii
10.356.295
10.449.501
10.511.639
10.573.777
1.941.805
1.959.282
1.970.932
1.982.583
5.404.759
5.453.402
5.485.831
5.518.259
9.850.510
9.939.165
9.998.268
10.057.371

RINGAN
SEDANG
541
N-1-12-i
542
N-1-12-ii
543
N-1-12-iii
544
N-1-20-i
3.145.429
3.173.737
3.192.610
3.211.483
545
N-1-20-ii
6.236.267
6.292.393
6.329.811
6.367.228
546
N-1-20-iii
7.133.724
7.197.927
7.240.730
7.283.532
547
N-1-30-i
3.742.043
3.775.721
3.798.173
3.820.625
548
N-1-30-ii
5.686.500
5.737.679
5.771.798
5.805.917
549
N-1-30-iii
6.546.100
6.605.014
6.644.291
6.683.568
550
N-1-40-i
3.371.947
3.402.294
3.422.526
3.442.757
551
N-1-40-ii
4.570.794
4.611.931
4.639.356
4.666.781
552
N-1-40-iii
5.315.965
5.363.809
5.395.705
5.427.601
553
N-4-10-i
1.315.180
1.327.017
1.334.908
1.342.799
554
N-4-10-ii
1.924.417
1.941.737
1.953.283
1.964.830
555
N-4-10-iii
3.792.407
3.826.539
3.849.293
3.872.047
556
N-4-11-i
1.100.593
1.110.498
1.117.102
1.123.705
557
N-4-11-ii
1.859.975
1.876.715
1.887.875
1.899.035
558
N-4-11-iii
2.128.419
2.147.575
2.160.345
2.173.116
559
N-4-12-i
1.064.222
1.073.800
1.080.185
1.086.571
560
N-4-12-ii
1.495.735
1.509.197
1.518.171
1.527.146
561
N-4-12-iii
2.393.338
2.414.878
2.429.238
2.443.598
562
N-4-13-i
BATU URIN RINGAN
1.516.860
1.530.512
1.539.613
1.548.714
563
N-4-13-ii
BATU URIN SEDANG
1.828.763
1.845.222
1.856.194
1.867.167
564
N-4-13-iii
BATU URIN BERAT
4.503.741
4.544.275
4.571.297
4.598.320
N-4-14-i

(RINGAN)
832.395
839.887
844.881
849.875
565

URIN BAWAH RINGAN
URIN BAWAH SEDANG
URIN BAWAH BERAT
RINGAN
SEDANG
BERAT
GINJAL RINGAN
GINJAL SEDANG
GINJAL BERAT
- 853 No
Kode
INA-CBG
566
N-4-14-ii
567
N-4-14-iii
568
N-4-15-i
569
N-4-15-ii
570
N-4-15-iii
571
N-4-16-i
572
N-4-16-ii
573
N-4-16-iii
574
O-6-10-i
575
O-6-10-ii
576
O-6-10-iii
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
584
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.281.784
1.293.320
1.301.010
1.308.701
2.078.645
2.097.352
2.109.824
2.122.296
1.477.477
1.490.774
1.499.639
1.508.504
2.027.558
2.045.806
2.057.971
2.070.137
2.313.810
2.334.634
2.348.517
2.362.400
1.483.857
1.497.212
1.506.115
1.515.018
1.921.979
1.939.277
1.950.809
1.962.341
4.041.636
4.078.011
4.102.261
4.126.511
2.836.209
2.861.735
2.878.752
2.895.770
3.148.624
3.176.962
3.195.854
3.214.746
3.466.551
3.497.750
3.518.550
3.539.349
1.479.778
1.493.096
1.501.974
1.510.853
1.898.419
1.915.505
1.926.895
1.938.286
3.217.231
3.246.186
3.265.489
3.284.793
1.288.597
1.300.194
1.307.926
1.315.657
1.547.601
1.561.530
1.570.815
1.580.101
1.944.339
1.961.839
1.973.505
1.985.171
923.077
931.385
936.923
942.462
O-6-13-ii
1.066.757
1.076.358
1.082.758
1.089.159
585
O-6-13-iii
1.326.654
1.338.594
1.346.553
1.354.513
586
P-8-01-i
24.145.669
24.362.980
24.507.854
24.652.729
587
P-8-01-ii
29.876.489
30.145.377
30.324.636
30.503.895
588
P-8-01-iii
35.066.623
35.382.222
35.592.622
35.803.022
589
P-8-02-i
35.000.277
35.315.279
35.525.281
35.735.283
590
P-8-02-ii
40.148.920
40.510.260
40.751.154
40.992.047
591
P-8-02-iii
45.873.012
46.285.869
46.561.107
46.836.345
592
P-8-03-i
1.618.171
1.632.735
1.642.444
1.652.153

(SEDANG)
(BERAT)
SALURAN URIN RINGAN
SALURAN URIN SEDANG
SALURAN URIN BERAT
RINGAN
SEDANG
BERAT
&KURET RINGAN
KURET SEDANG
KURET BERAT

- 854 No
Kode
INA-CBG
593
P-8-03-ii
594
P-8-03-iii
595
P-8-04-i
596
P-8-04-ii
597
P-8-04-iii
598
P-8-05-i
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii
603
P-8-06-iii
604
P-8-07-i
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
614
P-8-11-ii
615
P-8-11-iii
616
P-8-12-i
617
P-8-12-ii
618
P-8-12-iii
619
P-8-13-i
620
P-8-13-ii
Deskripsi (INA-CBG)
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
RINGAN
SEDANG
BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.265.439
2.285.828
2.299.421
2.313.014
3.896.051
3.931.116
3.954.492
3.977.868
17.289.836
17.445.445
17.549.184
17.652.923
22.438.479
22.640.426
22.775.057
22.909.687
32.171.132
32.460.672
32.653.699
32.846.725
9.401.652
9.486.267
9.542.677
9.599.087
13.325.575
13.445.505
13.525.458
13.605.412
19.633.445
19.810.146
19.927.947
20.045.748
1.316.577
1.328.426
1.336.326
1.344.225
3.883.611
3.918.563
3.941.865
3.965.166
7.119.953
7.184.032
7.226.752
7.269.472
2.498.484
2.520.970
2.535.961
2.550.952
6.351.747
6.408.913
6.447.023
6.485.134
8.414.489
8.490.220
8.540.707
8.591.194
1.964.177
1.981.855
1.993.640
2.005.425
2.788.426
2.813.522
2.830.252
2.846.983
3.936.401
3.971.828
3.995.447
4.019.065
1.218.573
1.229.540
1.236.852
1.244.163
1.765.281
1.781.168
1.791.760
1.802.352
3.465.766
3.496.958
3.517.753
3.538.547
1.351.124
1.363.284
1.371.391
1.379.498
7.306.677
7.372.437
7.416.277
7.460.117
7.459.753
7.526.891
7.571.649
7.616.408
1.619.137
1.633.709
1.643.424
1.653.139
2.517.477
2.540.134
2.555.239
2.570.344
2.970.090
2.996.821
3.014.642
3.032.462
836.857
844.389
849.410
854.431
1.548.598
1.562.535
1.571.827
1.581.118
- 855 No
Kode
INA-CBG
621
P-8-13-iii
622
P-8-14-i
623
P-8-14-ii
624
P-8-14-iii
625
P-8-15-i
626
P-8-15-ii
627
P-8-15-iii
628
P-8-16-i
629
P-8-16-ii
630
P-8-16-iii
631
P-8-17-i
632
P-8-17-ii
633
P-8-17-iii
634
S-4-10-i
635
S-4-10-ii
636
S-4-10-iii
637
S-4-11-i
638
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.316.094
2.336.939
2.350.835
2.364.732
1.529.025
1.542.787
1.551.961
1.561.135
3.121.837
3.149.933
3.168.664
3.187.395
3.424.643
3.455.465
3.476.013
3.496.561
1.149.875
1.160.224
1.167.123
1.174.022
2.298.297
2.318.982
2.332.772
2.346.561
2.699.706
2.724.003
2.740.201
2.756.400
1.040.908
1.050.277
1.056.522
1.062.767
1.476.573
1.489.862
1.498.722
1.507.581
1.916.664
1.933.914
1.945.414
1.956.914
685.750
691.922
696.036
700.151
2.281.972
2.302.510
2.316.202
2.329.894
4.606.016
4.647.470
4.675.106
4.702.742
960.990
969.639
975.404
981.170
1.201.237
1.212.048
1.219.256
1.226.463
1.561.402
1.575.455
1.584.823
1.594.191
600.618
606.024
609.628
613.231
S-4-11-ii
960.990
969.639
975.404
981.170
639
S-4-11-iii
1.478.939
1.492.250
1.501.123
1.509.997
640
S-4-12-i
720.742
727.229
731.553
735.878
641
S-4-12-ii
960.990
969.639
975.404
981.170
642
S-4-12-iii
1.876.889
1.893.781
1.905.042
1.916.303
643
S-4-13-i
1.023.996
1.033.212
1.039.356
1.045.500
644
S-4-13-ii
1.698.814
1.714.103
1.724.296
1.734.489
645
S-4-13-iii
3.459.002
3.490.133
3.510.887
3.531.641
646
S-4-14-i
585.513
590.783
594.296
597.809
647
S-4-14-ii
1.243.827
1.255.021
1.262.484
1.269.947
648
S-4-14-iii
2.358.738
2.379.967
2.394.120
2.408.272
649
S-4-15-i
442.829
446.815
449.472
452.129
650
S-4-15-ii
835.769
843.291
848.306
853.321
651
S-4-15-iii
1.082.516
1.092.258
1.098.753
1.105.248
652
S-4-16-i
1.681.732
1.696.867
1.706.958
1.717.048

MAYOR BERAT
ASPIRASI RINGAN
ASPIRASI SEDANG
ASPIRASI BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT

PASIEN RINGAN
PASIEN SEDANG
PASIEN BERAT
LUKA BAKAR RINGAN
- 856 No
Kode
INA-CBG
653
S-4-16-ii
654
S-4-16-iii
655
S-4-17-i
656
S-4-17-ii
657
S-4-17-iii
658
T-1-10-i
659
T-1-10-ii
660
T-1-10-iii
661
T-4-10-i
662
T-4-10-ii
663
T-4-10-iii
664
T-4-11-i
665
T-4-11-ii
666
T-4-11-iii
667
T-4-12-i
668
T-4-12-ii
669
T-4-12-iii
670
U-1-10-i
671
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
LUKA BAKAR SEDANG
2.841.662
2.867.237
2.884.287
2.901.337
LUKA BAKAR BERAT
5.074.229
5.119.897
5.150.342
5.180.788
1.072.862
1.082.517
1.088.954
1.095.392
1.249.458
1.260.703
1.268.200
1.275.696
1.958.854
1.976.484
1.988.237
1.999.990
1.107.489
1.117.457
1.124.102
1.130.746
1.487.283
1.500.668
1.509.592
1.518.516
2.705.852
2.730.205
2.746.440
2.762.675
404.917
408.561
410.991
413.420
771.682
778.627
783.257
787.887
1.121.816
1.131.912
1.138.643
1.145.374
479.091
483.403
486.277
489.152
753.952
760.738
765.262
769.785
1.214.395
1.225.325
1.232.611
1.239.898
840.866
848.434
853.479
858.524
1.270.923
1.282.361
1.289.986
1.297.612
1.977.099
1.994.893
2.006.755
2.018.618
895.025
903.080
908.450
913.820
U-1-10-ii
1.826.353
1.842.790
1.853.748
1.864.706
672
U-1-10-iii
7.886.561
7.957.540
8.004.859
8.052.179
673
U-1-11-i
3.883.611
3.918.563
3.941.865
3.965.166
674
U-1-11-ii
5.178.147
5.224.751
5.255.820
5.286.888
675
U-1-11-iii
10.408.485
10.502.162
10.564.613
10.627.063
676
U-1-12-i
2.839.465
2.865.020
2.882.057
2.899.093
677
U-1-12-ii
5.825.416
5.877.845
5.912.797
5.947.749
678
U-1-12-iii
7.564.413
7.632.492
7.677.879
7.723.265
679
U-1-13-i
2.589.074
2.612.375
2.627.910
2.643.444
680
U-1-13-ii
3.236.342
3.265.469
3.284.887
3.304.305
681
U-1-13-iii
5.632.854
5.683.550
5.717.347
5.751.144
682
U-1-14-i
1.709.158
1.724.540
1.734.795
1.745.050
683
U-1-14-ii
2.097.480
2.116.358
2.128.943
2.141.528

DOKTER RINGAN
DOKTER SEDANG
DOKTER BERAT

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)

- 857 No
Kode
INA-CBG
Deskripsi (INA-CBG)
684
U-1-14-iii
685
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.485.573
2.507.944
2.522.857
2.537.770
U-1-15-i
1.003.854
1.012.888
1.018.911
1.024.935
686
U-1-15-ii
1.426.406
1.439.244
1.447.802
1.456.360
687
U-1-15-iii
2.810.790
2.836.087
2.852.952
2.869.817
688
U-1-20-i
2.596.532
2.619.901
2.635.480
2.651.059
689
U-1-20-ii
4.588.924
4.630.224
4.657.758
4.685.291
690
U-1-20-iii
9.530.341
9.616.114
9.673.296
9.730.478
691
U-1-30-i
2.227.372
2.247.418
2.260.782
2.274.146
692
U-1-30-ii
3.006.952
3.034.014
3.052.056
3.070.098
693
U-1-30-iii
5.178.147
5.224.751
5.255.820
5.286.888
694
U-4-10-i
2.073.311
2.091.971
2.104.411
2.116.851
695
U-4-10-ii
5.197.355
5.244.131
5.275.316
5.306.500
696
U-4-10-iii
7.581.810
7.650.046
7.695.537
7.741.028
697
U-4-11-i
960.990
969.639
975.404
981.170
698
U-4-11-ii
1.441.484
1.454.458
1.463.107
1.471.756
699
U-4-11-iii
2.385.128
2.406.594
2.420.905
2.435.216
700
U-4-12-i
960.990
969.639
975.404
981.170
701
U-4-12-ii
1.340.332
1.352.395
1.360.437
1.368.479
702
U-4-12-iii
2.131.066
2.150.246
2.163.032
2.175.819
703
U-4-13-i
704
U-4-13-ii
705
U-4-13-iii
706


DAN TELINGA RINGAN
DAN TELINGA SEDANG
DAN TELINGA BERAT

960.990
969.639
975.404
981.170
1.097.573
1.107.451
1.114.037
1.120.622
1.490.986
1.504.404
1.513.350
1.522.296
U-4-14-i
1.201.237
1.212.048
1.219.256
1.226.463
707
U-4-14-ii
1.441.484
1.454.458
1.463.107
1.471.756
708
U-4-14-iii
2.414.736
2.436.469
2.450.957
2.465.446
709
U-4-15-i
960.990
969.639
975.404
981.170
710
U-4-15-ii
1.212.519
1.223.432
1.230.707
1.237.982
711
U-4-15-iii
1.682.058
1.697.196
1.707.289
1.717.381
712
V-1-10-i
2.840.137
2.865.698
2.882.739
2.899.780
713
V-1-10-ii
3.236.342
3.265.469
3.284.887
3.304.305
714
V-1-10-iii
6.149.050
6.204.391
6.241.286
6.278.180
715
V-1-11-i
3.236.342
3.265.469
3.284.887
3.304.305
716
V-1-11-ii
3.611.812
3.644.318
3.665.989
3.687.660

KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT
- 858 No
Kode
INA-CBG
717
V-1-11-iii
Deskripsi (INA-CBG)
NON KOMPLEK (BERAT)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.348.541
5.396.678
5.428.769
5.460.860
2.091.191
2.110.012
2.122.559
2.135.106
7.177.054
7.241.648
7.284.710
7.327.772
8.071.539
8.144.182
8.192.612
8.241.041
3.169.568
3.198.094
3.217.111
3.236.129
6.023.088
6.077.296
6.113.434
6.149.573
7.767.221
7.837.126
7.883.729
7.930.333
3.820.951
3.855.339
3.878.265
3.901.191
5.557.245
5.607.260
5.640.604
5.673.947
7.554.266
7.622.255
7.667.580
7.712.906
718
V-1-12-i
719
V-1-12-ii
720
V-1-12-iii
721
V-1-13-i
722
V-1-13-ii
723
V-1-13-iii
724
V-1-14-i
725
V-1-14-ii
726
V-1-14-iii
727
V-1-15-i
1.801.365
1.817.578
1.828.386
1.839.194
728
V-1-15-ii
3.030.315
3.057.587
3.075.769
3.093.951
729
V-1-15-iii
5.041.802
5.087.178
5.117.429
5.147.679
730
V-4-10-i
2.900.653
2.926.759
2.944.163
2.961.567
731
V-4-10-ii
3.746.540
3.780.259
3.802.738
3.825.217
732
V-4-10-iii
7.160.295
7.224.738
7.267.700
7.310.662
733
V-4-11-i
1.475.091
1.488.367
1.497.217
1.506.068
734
V-4-11-ii
2.155.343
2.174.741
2.187.673
2.200.605
735
V-4-11-iii
3.556.174
3.588.179
3.609.516
3.630.853
736
W-1-01-i
4.337.489
4.376.527
4.402.552
4.428.576
737
W-1-01-ii
5.224.300
5.271.319
5.302.664
5.334.010
738
W-1-01-iii
10.635.197
10.730.914
10.794.725
10.858.537
739
W-1-10-i
1.207.986
1.218.857
1.226.105
1.233.353
740
W-1-10-ii
2.254.299
2.274.588
2.288.114
2.301.639
741
W-1-10-iii
3.687.318
3.720.504
3.742.628
3.764.752
742
W-1-11-i
1.254.695
1.265.987
1.273.516
1.281.044
743
W-1-11-ii
2.419.839
2.441.617
2.456.136
2.470.655
744
W-1-11-iii
3.883.611
3.918.563
3.941.865
3.965.166
745
W-1-12-i
1.140.079
1.150.340
1.157.180
1.164.021
746
W-1-12-ii
1.296.248
1.307.914
1.315.692
1.323.469
747
W-1-12-iii
1.991.201
2.009.121
2.021.069
2.033.016
748
W-1-13-i
1.134.194
1.144.402
1.151.207
1.158.012

RINGAN
SEDANG
BERAT

SERVIK RINGAN
SERVIK SEDANG
SERVIK BERAT
ENDOSKOP RINGAN
- 859 No
Kode
INA-CBG
749
W-1-13-ii
750
W-1-13-iii
751
W-1-20-i
752
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.231.408
1.242.491
1.249.879
1.257.267
1.654.008
1.668.894
1.678.818
1.688.742
3.697.339
3.730.615
3.752.800
3.774.984
W-1-20-ii
5.178.147
5.224.751
5.255.820
5.286.888
753
W-1-20-iii
5.825.416
5.877.845
5.912.797
5.947.749
754
W-1-30-i
2.018.377
2.036.542
2.048.652
2.060.762
755
W-1-30-ii
3.219.415
3.248.390
3.267.706
3.287.023
756
W-1-30-iii
8.561.217
8.638.268
8.689.635
8.741.002
757
W-4-10-i
1.505.203
1.518.750
1.527.781
1.536.813
758
W-4-10-ii
2.034.451
2.052.761
2.064.968
2.077.174
759
W-4-10-iii
3.843.958
3.878.554
3.901.618
3.924.682
760
W-4-11-i
1.201.237
1.212.048
1.219.256
1.226.463
761
W-4-11-ii
1.921.979
1.939.277
1.950.809
1.962.341
762
W-4-11-iii
2.335.774
2.356.796
2.370.811
2.384.826
763
W-4-12-i
960.990
969.639
975.404
981.170
764
W-4-12-ii
1.460.907
1.474.055
1.482.820
1.491.586
765
W-4-12-iii
1.762.519
1.778.382
1.788.957
1.799.532
766
W-4-13-i
ABORTUS RINGAN
527.018
531.761
534.923
538.085
767
W-4-13-ii
ABORTUS SEDANG
720.742
727.229
731.553
735.878
768
W-4-13-iii
ABORTUS BERAT
960.990
969.639
975.404
981.170
769
W-4-14-i
720.742
727.229
731.553
735.878
770
W-4-14-ii
960.990
969.639
975.404
981.170
771
W-4-14-iii
1.166.438
1.176.936
1.183.935
1.190.933
772
W-4-15-i
719.062
725.533
729.848
734.162
773
W-4-15-ii
774.618
781.590
786.238
790.885
774
W-4-15-iii
980.030
988.850
994.730
1.000.610
775
W-4-16-i
720.742
727.229
731.553
735.878
776
W-4-16-ii
1.142.953
1.153.240
1.160.098
1.166.955
777
W-4-16-iii
1.456.669
1.469.779
1.478.519
1.487.259
778
W-4-17-i
704.292
710.631
714.857
719.083
779
W-4-17-ii
960.990
969.639
975.404
981.170
780
W-4-17-iii
1.818.001
1.834.363
1.845.271
1.856.179
781
Z-4-10-i
REHABILITASI RINGAN
1.648.944
1.663.785
1.673.679
1.683.572
782
Z-4-10-ii
REHABILITASI SEDANG
2.188.736
2.208.434
2.221.567
2.234.699

ENDOSKOP SEDANG
ENDOSKOP BERAT

RINGAN
SEDANG
BERAT

- 860 No
Kode
INA-CBG
783
Z-4-10-iii
784
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
REHABILITASI BERAT
3.109.308
3.137.291
3.155.947
3.174.603
Z-4-11-i
1.722.052
1.737.551
1.747.883
1.758.215
785
Z-4-11-ii
2.072.970
2.091.627
2.104.065
2.116.503
786
Z-4-11-iii
3.240.804
3.269.971
3.289.416
3.308.861
720.742
727.229
731.553
735.878
1.756.918
1.772.730
1.783.271
1.793.813
2.232.764
2.252.859
2.266.255
2.279.652
787
Z-4-12-i
788
Z-4-12-ii
789
Z-4-12-iii

- 861 2. RawatJalan
No
Kode
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
B-3-12-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
562,384
567,445
570,820
574,194
729,500
736,065
740,442
744,819
1,356,601
1,368,810
1,376,950
1,385,090
1,121,099
1,131,189
1,137,916
1,144,642
936,582
945,011
950,630
956,250
328,370
331,325
333,295
335,265
732,221
738,811
743,205
747,598

150,447
151,801
152,704
153,607
C-3-10-0
410,399
414,093
416,555
419,018
10
C-3-11-0

KANDUNG KEMIH
649,062
654,903
658,798
662,692
11
C-3-12-0
147,141
148,465
149,348
150,231
142,884
144,170
145,027
145,885
1,216,374
1,227,321
1,234,619
1,241,917
1,114,855
1,124,889
1,131,578
1,138,267

LAPAROSKOPI
PANKREAS
LAPAROSKOPI
EMPEDU

OVARIUM
GASTROINTESTINAL
GINJAL ATAU PROSTAT
12
C-3-13-0
13
C-3-14-0
14
C-3-15-0
15
C-3-16-0
252,822
255,098
256,615
258,132
16
C-3-17-0

LEHER
167,715
169,224
170,231
171,237
17
C-3-18-0
74,358
75,027
75,473
75,919
18
C-3-19-0

MYELOMA ATAU TESTIS
105,157
106,103
106,734
107,365
19
C-3-20-0
2,094,198
2,113,046
2,125,611
2,138,176
20
C-3-21-0
120,003
121,083
121,803
122,523
21
C-3-22-0
526,875
531,617
534,778
537,939
22
C-3-23-0
85,342
86,110
86,622
87,134
23
D-2-10-0

TULANG
723,032
729,539
733,877
738,215
24
D-2-11-0
PROSEDUR LIMPA
905,359
913,507
918,939
924,372
25
D-2-21-0
759,340
766,174
770,730
775,286
26
D-2-22-0
166,652
168,152
169,152
170,152
27
D-3-10-0
120,710
121,797
122,521
123,245
28
D-3-11-0
313,399
316,219
318,100
319,980
29
E-2-10-0
185,906
187,579
188,694
189,810
30
E-2-21-0
134,775
135,988
136,797
137,606
31
E-2-22-0
134,775
135,988
136,797
137,606

TYMUS
TYMUS
TULANG
PEMBENTUK DARAH
PARATIROID
THYROGLOSSAL
- 862 No
Kode
INA-CBG
32
E-3-10-0
33
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

ENDOKRIN
156,735
158,146
159,086
160,026
F-3-10-0
TERAPI SHOCK
218,640
220,608
221,920
223,232
34
F-5-10-0
267,905
270,316
271,924
273,531
35
F-5-11-0
TERAPI KELOMPOK
176,659
178,249
179,309
180,369
36
F-5-12-0
226,065
228,099
229,456
230,812
37
F-5-13-0
191,462
193,185
194,334
195,483
38
F-5-14-0
128,445
129,601
130,372
131,143
39
F-5-15-0
120,498
121,583
122,306
123,029
40
F-5-16-0
125,510
126,640
127,393
128,146
41
G-2-10-0
PROSEDUR KRANIOTOMI
105,690
106,641
107,275
107,909
42
G-2-11-0
916,161
924,407
929,904
935,401
43
G-2-12-0

EKSTRAKRANIAL
1,327,743
1,339,693
1,347,659
1,355,626
44
G-2-13-0
325,725
328,657
330,611
332,565
45
G-2-21-0
594,068
599,414
602,979
606,543
46
G-2-22-0
539,167
544,019
547,254
550,489
47
G-2-31-0
889,672
897,679
903,017
908,355
48
G-2-32-0
456,045
460,150
462,886
465,622
49
G-3-10-0
181,007
182,636
183,722
184,808
50
G-3-11-0
241,067
243,237
244,683
246,129
51
G-3-12-0
394,992
398,547
400,917
403,287
52
G-3-13-0
395,037
398,593
400,963
403,333
53
H-2-21-0
518,428
523,094
526,204
529,315
54
H-2-22-0
134,775
135,988
136,797
137,606
55
H-2-23-0
134,775
135,988
136,797
137,606
56
H-2-31-0
858,733
866,461
871,614
876,766
57
H-2-32-0
89,374
90,178
90,715
91,251
58
H-2-33-0
134,775
135,988
136,797
137,606
59
H-2-34-0
385,248
388,716
391,027
393,339
60
H-2-35-0
126,948
128,091
128,852
129,614
61
H-2-36-0
685,236
691,403
695,515
699,626
62
H-2-37-0

729,464
736,029
740,406
744,783
63
H-3-10-0
253,800
256,084
257,607
259,130
64
H-3-11-0
133,471
134,672
135,473
136,274

AKUT
MENTAL

MATA
MATA
MATA
MATA
MATA
- 863 No
Kode
INA-CBG
65
H-3-12-0
66
H-3-13-0
67
I-2-11-0
68
I-2-12-0
69
I-2-13-0
70
I-2-14-0
71
I-2-15-0
Deskripsi (INA-CBG)
MATA
TORASIK
ABDOMEN
PENGGANTIAN ALAT
DARAH VENA
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
139,350
140,604
141,441
142,277
135,301
136,518
137,330
138,142
1,560,306
1,574,348
1,583,710
1,593,072
1,097,065
1,106,939
1,113,521
1,120,103
1,394,304
1,406,852
1,415,218
1,423,584
2,467,620
2,489,829
2,504,635
2,519,441
148,398
149,733
150,624
151,514
1,558,614
1,572,642
1,581,994
1,591,345
513,830
518,455
521,538
524,621
72
I-2-16-0
73
I-2-17-0
74
I-2-21-0
1,203,029
1,213,856
1,221,074
1,228,292
75
I-2-22-0
1,132,862
1,143,058
1,149,855
1,156,652
76
I-2-23-0
231,837
233,923
235,314
236,705
77
I-2-31-0
1,803,074
1,819,301
1,830,120
1,840,938
78
I-2-32-0
2,357,784
2,379,004
2,393,150
2,407,297
79
I-2-41-0
1,580,923
1,595,151
1,604,637
1,614,122
80
I-2-42-0

LAIN
1,838,085
1,854,627
1,865,656
1,876,684
81
I-3-10-0
PROSEDUR RESUSITASI
233,328
235,428
236,828
238,228
82
I-3-11-0
123,150
124,259
124,998
125,736
83
I-3-12-0
715,703
722,144
726,438
730,733
84
I-3-13-0
235,065
237,180
238,590
240,001
85
I-3-14-0
150,668
152,024
152,928
153,832
133,471
134,672
135,473
136,274
826,365
833,802
838,761
843,719
133,210
134,409
135,208
136,007

PACU JANTUNG

KARDIOVASKULAR
PERNAFASAN
PENDEK
86
I-3-15-0
87
J-2-10-0
88
J-2-21-0
89
J-2-22-0
671,295
677,336
681,364
685,392
90
J-2-31-0
PROSEDUR
870,729
878,566
883,790
889,014
91
J-2-32-0
647,967
653,799
657,687
661,574
92
J-3-10-0
134,775
135,988
136,797
137,606
93
J-3-11-0

PADA DADA
380,851
384,279
386,564
388,849
94
J-3-12-0
147,141
148,465
149,348
150,231
95
J-3-13-0
216,555
218,504
219,803
221,102
96
J-3-14-0
229,897
231,966
233,345
234,724
- 864 No
Kode
INA-CBG
97
J-3-15-0
98
J-3-16-0
99
J-3-17-0
100
K-2-10-0
101
K-2-11-0
102
K-2-12-0
103
K-2-13-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
201,601
203,415
204,625
205,834
229,897
231,966
233,345
234,724
134,775
135,988
136,797
137,606
387,930
391,421
393,749
396,076
828,388
835,843
840,814
845,784

635,894
641,618
645,433
649,248
1,034,953
1,044,267
1,050,477
1,056,687
134,775
135,988
136,797
137,606
134,775
135,988
136,797
137,606
1,732,184
1,747,774
1,758,167
1,768,560
582,445
587,687
591,182
594,677
134,775
135,988
136,797
137,606

PERNAFASAN
KECIL

FEMORALIS
USUS BESAR
ATAS
ATAS
104
K-2-14-0
105
K-2-21-0
106
K-2-22-0
107
K-2-31-0
108
K-2-32-0
109
K-2-41-0
641,576
647,350
651,199
655,049
110
K-2-42-0

183,306
184,956
186,056
187,156
111
K-2-51-0
425,147
428,973
431,524
434,075
112
K-2-52-0
231,837
233,923
235,314
236,705
113
K-2-53-0
134,775
135,988
136,797
137,606
114
K-3-10-0

GASTROINTESTINAL
256,468
258,777
260,315
261,854
115
K-3-11-0
154,188
155,575
156,500
157,426
116
K-3-12-0
156,366
157,773
158,711
159,649
117
K-3-13-0
134,775
135,988
136,797
137,606
361,201
364,452
366,619
368,786
174,429
175,999
177,045
178,092
231,129
233,210
234,596
235,983
794,631
801,783
806,551
811,319
509,353
513,937
516,993
520,050
229,897
231,966
233,345
234,724
231,837
233,923
235,314
236,705

GASTROINTESTINAL
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
118
K-3-14-0
119
K-3-15-0
120
K-3-16-0
121
L-2-21-0
122
L-2-22-0
123
L-2-31-0
124
L-2-32-0
125
L-2-41-0
694,208
700,456
704,621
708,786
126
L-2-42-0

155,700
157,101
158,035
158,969
127
L-2-51-0
1,039,338
1,048,692
1,054,928
1,061,164
L-2-52-0

795,128
802,284
807,055
811,826
128
- 865 No
Kode
INA-CBG
129
L-2-53-0
130
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

134,775
135,988
136,797
137,606
L-3-10-0
183,306
184,956
186,056
187,156
131
L-3-11-0
178,003
179,605
180,673
181,741
132
L-3-12-0
135,566
136,786
137,600
138,413
133
M-2-10-0
1,063,319
1,072,889
1,079,269
1,085,648
134
M-2-21-0
952,275
960,846
966,560
972,273
135
M-2-22-0
231,837
233,923
235,314
236,705
136
M-2-31-0
PROSEDUR BUNION
578,412
583,617
587,088
590,558
137
M-2-32-0
183,306
184,956
186,056
187,156
138
M-2-41-0

TULANG
183,306
184,956
186,056
187,156
139
M-2-42-0
63,172
63,741
64,120
64,499
140
M-2-51-0
134,775
135,988
136,797
137,606
141
M-2-52-0
134,775
135,988
136,797
137,606
142
M-2-61-0
PROSEDUR ARTROSKOPI
660,604
666,550
670,514
674,477
143
M-2-62-0
134,775
135,988
136,797
137,606
664,178
670,156
674,141
678,126
905,802
913,954
919,389
924,824
134,775
135,988
136,797
137,606
668,720
674,738
678,751
682,763
645,343
651,151
655,023
658,895

DAN WAJAH
PAHA
PAHA

TULANG
WAJAH
WAJAH
BAWAH
BAWAH
144
M-2-63-0
145
M-2-64-0
146
M-2-65-0
147
M-2-71-0
148
M-2-72-0
149
M-2-81-0
962,344
971,005
976,779
982,553
150
M-2-82-0
699,081
705,373
709,567
713,762
151
M-2-83-0
134,775
135,988
136,797
137,606
152
M-2-84-0
134,775
135,988
136,797
137,606
153
M-3-10-0
384,675
388,137
390,445
392,753
154
M-3-11-0
213,279
215,198
216,478
217,758
155
M-3-12-0
482,314
486,654
489,548
492,442
156
M-3-13-0
157,247
158,662
159,606
160,549
157
M-3-14-0

TERTUTUP
268,762
271,181
272,793
274,406
158
M-3-15-0
118,406
119,472
120,182
120,893
159
M-3-16-0

134,775
135,988
136,797
137,606
160
M-3-17-0
147,141
148,465
149,348
150,231
161
N-2-11-0
1,780,514
1,796,539
1,807,222
1,817,905

PERGELANGAN TANGAN
PERGELANGAN TANGAN
MUSKULOSKELETAL
SKELETAL
- 866 No
Kode
INA-CBG
162
N-2-12-0
163
N-2-21-0
164
N-2-22-0
165
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1,030,010
1,039,280
1,045,460
1,051,640
1,024,581
1,033,802
1,039,949
1,046,097
231,837
233,923
235,314
236,705
N-2-23-0
231,837
233,923
235,314
236,705
166
N-2-24-0
749,219
755,962
760,457
764,953
167
N-2-31-0
630,721
636,397
640,182
643,966
168
N-2-32-0
231,837
233,923
235,314
236,705
169
N-2-41-0
231,837
233,923
235,314
236,705
170
N-2-42-0
392,081
395,609
397,962
400,314
171
N-3-10-0
231,837
233,923
235,314
236,705
172
N-3-11-0
268,616
271,034
272,645
274,257
173
N-3-12-0
207,571
209,440
210,685
211,930
174
N-3-13-0
231,837
233,923
235,314
236,705
175
N-3-14-0
199,483
201,278
202,475
203,672
176
N-3-15-0
511,525
516,128
519,198
522,267
177
O-7-10-0
85,403
86,171
86,684
87,196
178
O-7-11-0
470,335
474,568
477,390
480,212
179
O-7-12-0
171,265
172,806
173,834
174,861
180
O-7-13-0
95,181
96,038
96,609
97,180
181
P-9-10-0
126,948
128,091
128,852
129,614
182
P-9-11-0
126,948
128,091
128,852
129,614
183
P-9-12-0
126,948
128,091
128,852
129,614
184
P-9-13-0
126,948
128,091
128,852
129,614
185
P-9-14-0
126,948
128,091
128,852
129,614
186
P-9-15-0
80,919
81,648
82,133
82,619
187
P-9-16-0
126,948
128,091
128,852
129,614
188
P-9-17-0
126,402
127,540
128,298
129,057
189
Q-5-10-0
165,454
166,943
167,936
168,928
190
Q-5-11-0
124,003
125,119
125,863
126,607
191
Q-5-12-0
GIGI
109,293
110,277
110,932
111,588
192
Q-5-13-0
MEDICAL CHECK-UP
83,058
83,805
84,304
84,802
193
Q-5-14-0
91,391
92,213
92,762
93,310


DAN URETHRA
DAN URETHRA
TRANSURETHRA
TRANSURETHRA
SALURAN KEMIH
KEMIH
KEMIH
PROSEDUR DIALISIS
CAESAR
VAGINAL/JALAN LAHIR

ASPIRASI
- 867 No
Kode
INA-CBG
194
Q-5-15-0
195
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
62,850
63,415
63,792
64,169
Q-5-16-0
VAKSINASI
71,034
71,674
72,100
72,526
196
Q-5-17-0
PASANG INFUS
61,443
61,996
62,365
62,733
197
Q-5-18-0
115,655
116,696
117,390
118,084
198
Q-5-19-0
129,295
130,459
131,235
132,010
199
Q-5-20-0
ABORSI MENGANCAM
86,662
87,442
87,962
88,482
200
Q-5-21-0
ABORSI
85,482
86,251
86,764
87,277
201
Q-5-22-0
91,391
92,213
92,762
93,310
202
Q-5-23-0
111,887
112,894
113,565
114,236
203
Q-5-24-0
76,417
77,105
77,563
78,022
204
Q-5-25-0
119,171
120,243
120,958
121,673
205
Q-5-26-0
BRONKIAL AKUT
168,678
170,196
171,208
172,220
206
Q-5-27-0
120,039
121,120
121,840
122,560
207
Q-5-28-0
97,409
98,286
98,870
99,454
208
Q-5-29-0

JANTUNG LAIN-LAIN
275,781
278,263
279,917
281,572
209
Q-5-30-0
319,600
322,476
324,394
326,311
210
Q-5-31-0
FRAKTUR
114,020
115,047
115,731
116,415
211
Q-5-32-0
SALURAN KEMIH AKUT
132,061
133,250
134,042
134,835
212
Q-5-33-0
HEMATOLOGI AKUT
138,268
139,512
140,342
141,171
213
Q-5-34-0
INFEKSI VIRUS HIV
196,419
198,187
199,365
200,544
214
Q-5-35-0
INFEKSI AKUT
222,734
224,739
226,075
227,411
215
Q-5-36-0
259,388
261,723
263,279
264,835
216
Q-5-37-0

SHOCK
132,301
133,492
134,286
135,079
217
Q-5-38-0
PARU AKUT
176,428
178,016
179,074
180,133
218
Q-5-39-0
112,901
113,917
114,594
115,272
219
Q-5-40-0
110,774
111,771
112,435
113,100
220
Q-5-41-0
153,351
154,731
155,651
156,571
221
Q-5-42-0
120,233
121,315
122,036
122,758
222
Q-5-43-0
173,142
174,701
175,740
176,778
223
Q-5-44-0
141,308
142,580
143,428
144,276
224
T-2-10-0

TERAPI DETOKSIKASI
73,294
73,954
74,394
74,833
225
U-2-10-0
978,194
986,998
992,867
998,736
226
U-2-11-0

LEHER
1,162,692
1,173,157
1,180,133
1,187,109
227
U-2-12-0
127,927
129,078
129,845
130,613
- 868 No
Kode
INA-CBG
228
U-2-13-0
229
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
167,715
169,224
170,231
171,237
U-2-14-0
311,538
314,342
316,211
318,080
230
U-2-15-0
177,009
178,602
179,664
180,726
231
U-2-21-0
206,188
208,044
209,281
210,518
232
U-2-22-0
398,372
401,957
404,347
406,738
233
U-2-23-0
521,996
526,694
529,826
532,958
234
U-2-24-0
439,929
443,888
446,528
449,168
235
U-2-25-0
167,715
169,224
170,231
171,237
236
U-2-31-0
134,775
135,988
136,797
137,606
237
U-2-32-0
167,715
169,224
170,231
171,237
238
U-3-10-0
160,344
161,787
162,749
163,711
239
U-3-11-0
170,236
171,768
172,789
173,811
240
U-3-12-0
75,278
75,955
76,407
76,859
241
U-3-13-0
165,467
166,956
167,949
168,942
242
U-3-14-0
152,030
153,398
154,310
155,222
243
U-3-15-0
132,584
133,777
134,572
135,368
244
U-3-16-0
PROSEDUR PADA GIGI
149,530
150,876
151,773
152,670
245
V-2-10-0

PROSTAT
1,458,840
1,471,970
1,480,723
1,489,476
246
V-2-11-0
164,520
166,001
166,988
167,975
525,007
529,732
532,882
536,032
231,837
233,923
235,314
236,705
231,837
233,923
235,314
236,705

(RHINOPLASTY)

RONGGA HIDUNG
TENGGOROKAN
PROSEDUR PADA PENIS

SKROTUM
SKROTUM
TRANSURETHRAL
247
V-2-12-0
248
V-2-13-0
249
V-2-14-0
250
V-2-15-0
SIRKUMSISI/SUNAT
126,948
128,091
128,852
129,614
251
V-3-10-0
264,759
267,142
268,730
270,319
252
V-3-11-0
560,102
565,143
568,504
571,864
253
V-3-12-0
323,362
326,272
328,212
330,152
254
W-2-10-0
118,406
119,472
120,182
120,893
255
W-2-11-0
302,602
305,325
307,141
308,957
256
W-2-12-0
560,102
565,143
568,504
571,864
257
W-2-13-0
89,830
90,639
91,178
91,717
258
W-2-21-0
1,125,954
1,136,088
1,142,844
1,149,599
259
W-2-22-0
118,406
119,472
120,182
120,893

PROSEDUR ABORSI
RAHIM & LEHER RAHIM
TERHALANG/TERGANGGU
TERHALANG/TERGANGGU
PANGGUL TERBUKA
PANGGUL TERBUKA
- 869 No
Kode
INA-CBG
260
W-2-23-0
Deskripsi (INA-CBG)
JALAN LAHIR
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
395,127
398,683
401,054
403,425
1,297,082
1,308,756
1,316,538
1,324,321
909,702
917,890
923,348
928,806
261
W-2-31-0
262
W-2-32-0
263
W-2-33-0
386,636
390,115
392,435
394,755
264
W-2-34-0
131,502
132,685
133,474
134,263
265
W-3-10-0
319,600
322,476
324,394
326,311
266
W-3-11-0
255,479
257,778
259,311
260,844
267
W-3-12-0
118,406
119,472
120,182
120,893
268
Z-3-10-0
1,340,515
1,352,580
1,360,623
1,368,666
269
Z-3-11-0

EMPEDU
1,024,581
1,033,802
1,039,949
1,046,097
270
Z-3-12-0
171,080
172,620
173,646
174,673
271
Z-3-13-0

LAIN-LAIN
1,043,978
1,053,374
1,059,638
1,065,902
272
Z-3-14-0
DIAGNOSTIK TIDUR
206,427
208,285
209,523
210,762
273
Z-3-15-0
134,775
135,988
136,797
137,606
274
Z-3-16-0

(MRI)
432,588
436,481
439,077
441,672
275
Z-3-17-0
PENGOBATAN NUKLIR
181,610
183,244
184,334
185,424
276
Z-3-18-0
CT-SCAN KEPALA
174,977
176,552
177,602
178,652
277
Z-3-19-0
CT SCAN LAIN-LAIN
182,118
183,757
184,849
185,942
278
Z-3-20-0
123,863
124,977
125,720
126,464
279
Z-3-21-0
118,406
119,472
120,182
120,893
280
Z-3-22-0
133,492
134,694
135,495
136,296
281
Z-3-23-0
139,044
140,295
141,129
141,964
282
Z-3-24-0
273,193
275,652
277,291
278,930
283
Z-3-25-0
121,680
122,775
123,505
124,235
284
Z-3-26-0
137,522
138,760
139,585
140,410
285
Z-3-27-0
PERAWATAN LUKA
131,297
132,478
133,266
134,054
286
Z-3-28-0
IMAGING PAYUDARA
134,775
135,988
136,797
137,606
287
Z-3-29-0
IMAGING LAIN-LAIN
388,447
391,943
394,274
396,604
288
Z-3-30-0
FOTOTERAPI
65,555
66,145
66,539
66,932
- 870 B. RUMAH SAKIT KHUSUS KELAS D

1. RUMAH SAKIT JIWAKELAS D
a. RawatInap
No
Kode
INA-CBG
A-4-10-i
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
SEPTIKEMIA RINGAN
1.637.375
1.686.496
1.719.243
1.751.991
A-4-10-ii
SEPTIKEMIA SEDANG
2.798.420
2.882.373
2.938.341
2.994.310
A-4-10-iii
SEPTIKEMIA BERAT
3.314.194
3.413.620
3.479.904
3.546.188
A-4-11-i
4.393.533
4.525.339
4.613.209
4.701.080
A-4-11-ii

SEDANG
6.787.500
6.991.125
7.126.875
7.262.625
A-4-11-iii
11.102.867
11.435.953
11.658.011
11.880.068
A-4-12-i
DEMAM RINGAN
1.281.320
1.319.759
1.345.386
1.371.012
A-4-12-ii
DEMAM SEDANG
2.471.997
2.546.157
2.595.597
2.645.036
A-4-12-iii
DEMAM BERAT
2.829.019
2.913.889
2.970.470
3.027.050
10
A-4-13-i
1.601.650
1.649.699
1.681.732
1.713.765
11
A-4-13-ii
1.921.980
1.979.639
2.018.079
2.056.518
12
A-4-13-iii
2.335.939
2.406.017
2.452.736
2.499.455
13
A-4-14-i
1.507.503
1.552.728
1.582.878
1.613.028
14
A-4-14-ii
2.458.735
2.532.497
2.581.671
2.630.846
15
A-4-14-iii
2.743.876
2.826.192
2.881.070
2.935.947
16
A-4-15-i
INFEKSI HIV RINGAN
2.015.239
2.075.697
2.116.001
2.156.306
17
A-4-15-ii
INFEKSI HIV SEDANG
2.882.970
2.969.459
3.027.118
3.084.778
18
A-4-15-iii
INFEKSI HIV BERAT
5.393.230
5.555.027
5.662.892
5.770.756
19
B-1-01-i
21.522.670
22.168.350
22.598.804
23.029.257
20
B-1-01-ii
23.745.259
24.457.617
24.932.522
25.407.427
21
B-1-01-iii
41.654.071
42.903.693
43.736.775
44.569.856
22
B-1-10-i
2.790.341
2.874.051
2.929.858
2.985.665
23
B-1-10-ii
7.111.133
7.324.467
7.466.690
7.608.913
24
B-1-10-iii
16.483.280
16.977.778
17.307.444
17.637.109
2.540.292
2.616.500
2.667.306
2.718.112
6.376.372
6.567.663
6.695.190
6.822.718
7.994.388
8.234.219
8.394.107
8.553.995
5.418.534
5.581.090
5.689.460
5.797.831
11.613.243
11.961.640
12.193.905
12.426.170
13.807.259
14.221.477
14.497.622
14.773.767
25
B-1-11-i
26
B-1-11-ii
27
B-1-11-iii
28
B-1-12-i
29
B-1-12-ii
30
B-1-12-iii

LAIN-LAIN RINGAN
LAIN-LAIN SEDANG
LAIN-LAIN BERAT

(RINGAN)
(SEDANG)
(BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT
- 871 No
Kode
INA-CBG
31
B-1-13-i
32
B-1-13-ii
33
B-1-13-iii
34
B-1-14-i
35
B-1-14-ii
36
B-1-14-iii
37
B-4-10-i
38
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.550.645
3.657.164
3.728.177
3.799.190
5.783.485
5.956.989
6.072.659
6.188.329
8.526.479
8.782.274
8.952.803
9.123.333
4.821.525
4.966.171
5.062.602
5.159.032
5.362.509
5.523.385
5.630.635
5.737.885
8.389.008
8.640.679
8.808.459
8.976.239
1.348.989
1.389.459
1.416.439
1.443.419
B-4-10-ii
1.954.204
2.012.830
2.051.914
2.090.998
39
B-4-10-iii
3.293.796
3.392.610
3.458.485
3.524.361
40
B-4-11-i
3.256.966
3.354.675
3.419.814
3.484.954
41
B-4-11-ii
4.951.402
5.099.944
5.198.972
5.298.000
42
B-4-11-iii
5.332.832
5.492.817
5.599.473
5.706.130
43
B-4-12-i
2.857.765
2.943.498
3.000.653
3.057.808
44
B-4-12-ii
4.051.607
4.173.155
4.254.187
4.335.220
45
B-4-12-iii
7.699.985
7.930.984
8.084.984
8.238.984
46
B-4-13-i
1.921.980
1.979.639
2.018.079
2.056.518
47
B-4-13-ii
2.798.065
2.882.007
2.937.968
2.993.929
48
B-4-13-iii
4.623.820
4.762.534
4.855.011
4.947.487
49
B-4-14-i
2.474.815
2.549.059
2.598.555
2.648.052
50
B-4-14-ii
2.781.009
2.864.440
2.920.060
2.975.680
51
B-4-14-iii
3.537.709
3.643.840
3.714.594
3.785.348
52
C-4-10-i
2.517.521
2.593.046
2.643.397
2.693.747
53
C-4-10-ii
4.891.279
5.038.017
5.135.843
5.233.669
54
C-4-10-iii
LEUKEMIA AKUT BERAT
7.218.329
7.434.879
7.579.246
7.723.612
55
C-4-11-i
2.532.617
2.608.596
2.659.248
2.709.901
56
C-4-11-ii
2.901.922
2.988.979
3.047.018
3.105.056
57
C-4-11-iii
5.860.325
6.036.135
6.153.341
6.270.548
58
C-4-12-i
RADIOTERAPI RINGAN
1.281.320
1.319.759
1.345.386
1.371.012
59
C-4-12-ii
RADIOTERAPI SEDANG
4.745.333
4.887.693
4.982.600
5.077.506
60
C-4-12-iii
RADIOTERAPI BERAT
9.633.977
9.922.996
10.115.676
10.308.356
61
C-4-13-i
KEMOTERAPI RINGAN
1.281.320
1.319.759
1.345.386
1.371.012
62
C-4-13-ii
KEMOTERAPI SEDANG
2.562.640
2.639.519
2.690.772
2.742.024
63
C-4-13-iii
KEMOTERAPI BERAT
3.353.024
3.453.615
3.520.676
3.587.736

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT

PANCREAS RINGAN
PANCREAS SEDANG
PANCREAS BERAT
(RINGAN)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT
- 872 No
Kode
INA-CBG
64
C-4-14-i
65
C-4-14-ii
66
C-4-14-iii
67
D-1-10-i
68
D-1-10-ii
69
D-1-10-iii
70
D-1-11-i
71
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.234.926
2.301.974
2.346.673
2.391.371
3.265.818
3.363.792
3.429.108
3.494.425
4.978.644
5.128.004
5.227.576
5.327.149
13.772.036
14.185.197
14.460.638
14.736.079
20.975.867
21.605.143
22.024.661
22.444.178
28.428.032
29.280.873
29.849.433
30.417.994
3.769.660
3.882.750
3.958.143
4.033.537
D-1-11-ii
8.630.248
8.889.156
9.061.761
9.234.365
72
D-1-11-iii
13.527.262
13.933.079
14.203.625
14.474.170
73
D-1-20-i
3.452.099
3.555.662
3.624.704
3.693.746
74
D-1-20-ii
9.507.448
9.792.672
9.982.820
10.172.969
75
D-1-20-iii
15.102.934
15.556.022
15.858.081
16.160.140
76
D-4-10-i
1.484.878
1.529.425
1.559.122
1.588.820
77
D-4-10-ii
2.485.189
2.559.745
2.609.449
2.659.153
78
D-4-10-iii
3.477.251
3.581.568
3.651.113
3.720.658
79
D-4-11-i
1.601.650
1.649.699
1.681.732
1.713.765
80
D-4-11-ii
3.627.047
3.735.858
3.808.399
3.880.940
81
D-4-11-iii
5.494.471
5.659.305
5.769.194
5.879.084
82
D-4-12-i
1.659.529
1.709.314
1.742.505
1.775.696
83
D-4-12-ii
2.301.929
2.370.987
2.417.026
2.463.064
84
D-4-12-iii
3.534.613
3.640.652
3.711.344
3.782.036
85
D-4-13-i
1.281.320
1.319.759
1.345.386
1.371.012
86
D-4-13-ii
1.921.980
1.979.639
2.018.079
2.056.518
87
D-4-13-iii
2.656.032
2.735.713
2.788.834
2.841.955
88
D-4-14-i
1.601.650
1.649.699
1.681.732
1.713.765
89
D-4-14-ii
3.604.475
3.712.609
3.784.699
3.856.788
90
D-4-14-iii
4.299.640
4.428.629
4.514.622
4.600.615
91
E-1-01-i
4.131.427
4.255.370
4.337.998
4.420.627
92
E-1-01-ii
5.411.776
5.574.129
5.682.365
5.790.600
93
E-1-01-iii
10.727.041
11.048.852
11.263.393
11.477.934
94
E-1-10-i
3.161.161
3.255.996
3.319.219
3.382.443
95
E-1-10-ii
3.836.908
3.952.015
4.028.753
4.105.491
96
E-1-10-iii
8.087.072
8.329.684
8.491.426
8.653.167

RINGAN
SEDANG
BERAT
TULANG RINGAN
TULANG SEDANG
TULANG BERAT


RINGAN
SEDANG
BERAT
- 873 No
Kode
INA-CBG
97
E-1-20-i
98
E-1-20-ii
99
E-1-20-iii
100
E-4-10-i
101
E-4-10-ii
102
E-4-10-iii
103
E-4-11-i
104
E-4-11-ii
105
E-4-11-iii
106
E-4-12-i
107
E-4-12-ii
108
E-4-12-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.874.923
5.021.171
5.118.669
5.216.167
6.529.172
6.725.047
6.855.630
6.986.214
14.466.799
14.900.803
15.190.139
15.479.475
2.000.317
2.060.327
2.100.333
2.140.340
3.063.986
3.155.906
3.217.185
3.278.465
5.197.067
5.352.979
5.456.920
5.560.861
1.838.139
1.893.283
1.930.046
1.966.809
3.477.444
3.581.767
3.651.316
3.720.865
5.734.465
5.906.499
6.021.188
6.135.877
1.761.815
1.814.669
1.849.906
1.885.142
2.882.970
2.969.459
3.027.118
3.084.778
4.631.833
4.770.788
4.863.425
4.956.062
2.316.687
2.386.188
2.432.521
2.478.855
3.977.768
4.097.101
4.176.656
4.256.212
6.882.543
7.089.019
7.226.670
7.364.321

RINGAN
SEDANG
BERAT

RINGAN
SEDANG
BERAT
109
E-4-13-i
110
E-4-13-ii
111
E-4-13-iii
112
F-4-10-i
SCHIZOFRENIA RINGAN
1.899.531
1.956.517
1.994.508
2.032.498
113
F-4-10-ii
SCHIZOFRENIA SEDANG
2.109.491
2.172.775
2.214.965
2.257.155
114
F-4-10-iii
SCHIZOFRENIA BERAT
3.123.147
3.216.842
3.279.305
3.341.768
115
F-4-11-i
1.750.908
1.803.435
1.838.453
1.873.471
116
F-4-11-ii
2.039.974
2.101.173
2.141.972
2.182.772
117
F-4-11-iii
DEPRESI MAYOR BERAT
2.615.992
2.694.472
2.746.791
2.799.111

IMPULSE RINGAN
IMPULSE SEDANG
IMPULSE BERAT
960.990
989.820
1.009.039
1.028.259
1.372.157
1.413.322
1.440.765
1.468.208
2.976.665
3.065.965
3.125.498
3.185.031
118
F-4-12-i
119
F-4-12-ii
120
F-4-12-iii
121
F-4-13-i
1.414.999
1.457.449
1.485.749
1.514.049
122
F-4-13-ii
1.873.823
1.930.038
1.967.514
2.004.991
123
F-4-13-iii
2.416.055
2.488.537
2.536.858
2.585.179
124
F-4-14-i
DEPRESI RINGAN
990.500
1.020.215
1.040.025
1.059.835
125
F-4-14-ii
DEPRESI SEDANG
1.270.517
1.308.632
1.334.043
1.359.453
126
F-4-14-iii
DEPRESI BERAT
1.709.537
1.760.823
1.795.014
1.829.204
127
F-4-15-i
1.281.320
1.319.759
1.345.386
1.371.012
128
F-4-15-ii
1.921.980
1.979.639
2.018.079
2.056.518
129
F-4-15-iii
2.531.365
2.607.306
2.657.933
2.708.561
- 874 No
Kode
INA-CBG
130
F-4-16-i
131
F-4-16-ii
132
F-4-16-iii
133
F-4-17-i
134
F-4-17-ii
135
F-4-17-iii
136
F-4-18-i
137
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.536.423
2.612.515
2.663.244
2.713.972
2.948.528
3.036.984
3.095.954
3.154.925
3.935.793
4.053.866
4.132.582
4.211.298
649.240
668.717
681.702
694.686
1.902.859
1.959.945
1.998.002
2.036.059
2.030.211
2.091.117
2.131.721
2.172.326
2.198.486
2.264.440
2.308.410
2.352.380
F-4-18-ii
2.418.955
2.491.524
2.539.903
2.588.282
138
F-4-18-iii
3.729.030
3.840.901
3.915.482
3.990.063
139
F-4-19-i
1.686.031
1.736.612
1.770.333
1.804.053
140
F-4-19-ii
2.159.006
2.223.776
2.266.957
2.310.137
141
F-4-19-iii
2.687.992
2.768.631
2.822.391
2.876.151
142
G-1-01-i
6.002.297
6.182.366
6.302.412
6.422.458
143
G-1-01-ii
10.159.611
10.464.400
10.667.592
10.870.784
144
G-1-01-iii
19.667.873
20.257.909
20.651.267
21.044.624
145
G-1-10-i
3.989.024
4.108.695
4.188.476
4.268.256
146
G-1-10-ii
5.631.511
5.800.456
5.913.086
6.025.717
147
G-1-10-iii
6.674.543
6.874.780
7.008.270
7.141.761
148
G-1-11-i
4.601.459
4.739.503
4.831.532
4.923.561
149
G-1-11-ii
9.449.442
9.732.926
9.921.914
10.110.903
150
G-1-11-iii
17.260.496
17.778.311
18.123.521
18.468.731
151
G-1-12-i
3.578.579
3.685.937
3.757.508
3.829.080
152
G-1-12-ii
7.767.223
8.000.240
8.155.584
8.310.929
153
G-1-12-iii
11.484.302
11.828.831
12.058.517
12.288.203
154
G-1-13-i
708.708
729.969
744.144
758.318
155
G-1-13-ii
1.903.512
1.960.617
1.998.687
2.036.758
156
G-1-13-iii
4.295.124
4.423.978
4.509.881
4.595.783
4.509.314
4.644.594
4.734.780
4.824.966
6.092.231
6.274.998
6.396.843
6.518.688
14.916.112
15.363.595
15.661.917
15.960.240

RINGAN
SEDANG
BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

RINGAN
SEDANG
BERAT
157
G-1-20-i
158
G-1-20-ii
159
G-1-20-iii
160
G-1-30-i
5.751.224
5.923.761
6.038.786
6.153.810
161
G-1-30-ii
15.011.247
15.461.584
15.761.809
16.062.034
162
G-1-30-iii
19.324.114
19.903.837
20.290.320
20.676.802
- 875 No
Kode
INA-CBG
163
G-4-10-i
164
G-4-10-ii
165
G-4-10-iii
166
G-4-11-i
167
G-4-11-ii
168
G-4-11-iii
169
G-4-12-i
170
G-4-12-ii
171
G-4-12-iii
172
G-4-13-i
173
G-4-13-ii
174
G-4-13-iii
175
G-4-14-i
176
G-4-14-ii
177
G-4-14-iii
178
G-4-15-i
179
G-4-15-ii
180
G-4-15-iii
181
G-4-16-i
182
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.921.980
1.979.639
2.018.079
2.056.518
2.628.419
2.707.271
2.759.840
2.812.408
4.607.819
4.746.054
4.838.210
4.930.367
4.265.493
4.393.458
4.478.767
4.564.077
4.947.972
5.096.411
5.195.370
5.294.330
7.251.338
7.468.878
7.613.905
7.758.931
3.190.213
3.285.920
3.349.724
3.413.528
4.019.669
4.140.259
4.220.652
4.301.045
5.838.090
6.013.233
6.129.995
6.246.756
1.775.013
1.828.264
1.863.764
1.899.264
2.466.271
2.540.259
2.589.585
2.638.910
2.878.802
2.965.166
3.022.742
3.080.318
3.246.235
3.343.622
3.408.546
3.473.471
5.341.151
5.501.386
5.608.209
5.715.032
6.687.243
6.887.861
7.021.605
7.155.350
2.149.666
2.214.156
2.257.149
2.300.143
2.669.505
2.749.590
2.802.981
2.856.371
3.933.889
4.051.905
4.130.583
4.209.261
1.793.935
1.847.753
1.883.632
1.919.511
G-4-16-ii
2.595.557
2.673.424
2.725.335
2.777.246
183
G-4-16-iii
4.566.934
4.703.942
4.795.280
4.886.619
184
G-4-17-i
3.078.810
3.171.174
3.232.751
3.294.327
185
G-4-17-ii
3.820.939
3.935.567
4.011.986
4.088.405
186
G-4-17-iii
6.403.925
6.596.043
6.724.121
6.852.200
187
G-4-18-i
1.938.220
1.996.366
2.035.131
2.073.895
188
G-4-18-ii
3.706.815
3.818.019
3.892.155
3.966.292
189
G-4-18-iii
3.926.993
4.044.802
4.123.342
4.201.882
190
G-4-19-i
2.153.232
2.217.829
2.260.894
2.303.959
191
G-4-19-ii
3.814.096
3.928.519
4.004.801
4.081.083

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
DEGENERATIF RINGAN
DEGENERATIF SEDANG
DEGENERATIF BERAT
RINGAN
SEDANG
BERAT
TRAUMATIK RINGAN
TRAUMATIK SEDANG
TRAUMATIK BERAT
DENGAN INFARK BERAT
TANPA INFARK RINGAN
TANPA INFARK SEDANG
TANPA INFARK BERAT

PERIFER RINGAN
PERIFER SEDANG
PERIFER BERAT
PERSARAFAN RINGAN
PERSARAFAN SEDANG
PERSARAFAN BERAT
RINGAN
SEDANG
- 876 No
Kode
INA-CBG
192
G-4-19-iii
193
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

5.426.145
5.588.930
5.697.453
5.805.976
G-4-20-i
1.264.489
1.302.424
1.327.714
1.353.003
194
G-4-20-ii
1.740.116
1.792.320
1.827.122
1.861.924
195
G-4-20-iii
2.874.182
2.960.408
3.017.891
3.075.375
196
G-4-21-i
1.747.506
1.799.931
1.834.881
1.869.831
197
G-4-21-ii
2.429.033
2.501.904
2.550.485
2.599.066
198
G-4-21-iii
4.263.915
4.391.832
4.477.110
4.562.389
199
G-4-22-i
1.281.320
1.319.759
1.345.386
1.371.012
200
G-4-22-ii
1.601.650
1.649.699
1.681.732
1.713.765
201
G-4-22-iii
1.837.511
1.892.636
1.929.387
1.966.137
202
G-4-23-i
1.576.014
1.623.294
1.654.814
1.686.335
203
G-4-23-ii
1.639.440
1.688.623
1.721.412
1.754.201
204
G-4-23-iii
2.334.160
2.404.185
2.450.868
2.497.551
205
G-4-24-i
1.319.473
1.359.057
1.385.447
1.411.836
206
G-4-24-ii
1.912.720
1.970.102
2.008.356
2.046.611
207
G-4-24-iii
TRAUMA KEPALA BERAT
3.694.524
3.805.360
3.879.251
3.953.141
208
G-4-25-i
GEGAR OTAK RINGAN
1.281.320
1.319.759
1.345.386
1.371.012
209
G-4-25-ii
GEGAR OTAK SEDANG
1.601.650
1.649.699
1.681.732
1.713.765
210
G-4-25-iii
GEGAR OTAK BERAT
1.999.964
2.059.963
2.099.962
2.139.962
211
G-4-26-i
2.597.326
2.675.246
2.727.192
2.779.139
212
G-4-26-ii
2.945.454
3.033.818
3.092.727
3.151.636
213
G-4-26-iii
4.323.349
4.453.049
4.539.516
4.625.983
214
H-1-20-i
2.477.354
2.551.674
2.601.221
2.650.768
215
H-1-20-ii
4.517.735
4.653.267
4.743.621
4.833.976
216
H-1-20-iii
6.143.837
6.328.152
6.451.029
6.573.905
2.425.565
2.498.332
2.546.843
2.595.355
2.765.144
2.848.098
2.903.401
2.958.704

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)

RINGAN
SEDANG
217
H-1-30-i
218
H-1-30-ii
219
H-1-30-iii
4.613.543
4.751.949
4.844.220
4.936.491
220
H-4-10-i
2.197.156
2.263.070
2.307.014
2.350.957
221
H-4-10-ii
3.577.019
3.684.330
3.755.870
3.827.411
222
H-4-10-iii
5.616.371
5.784.863
5.897.190
6.009.517
223
H-4-11-i
1.760.278
1.813.086
1.848.292
1.883.497
224
H-4-11-ii
1.943.009
2.001.299
2.040.159
2.079.019
225
H-4-11-iii
2.577.959
2.655.298
2.706.857
2.758.416
- 877 No
Kode
INA-CBG
226
H-4-12-i
227
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.442.315
2.515.584
2.564.431
2.613.277
H-4-12-ii
3.308.275
3.407.523
3.473.689
3.539.854
228
H-4-12-iii
5.519.632
5.685.220
5.795.613
5.906.006
229
I-1-01-i
27.921.247
28.758.884
29.317.309
29.875.734
230
I-1-01-ii
28.535.660
29.391.729
29.962.443
30.533.156
231
I-1-01-iii
45.042.991
46.394.281
47.295.141
48.196.001
232
I-1-02-i
15.490.547
15.955.263
16.265.074
16.574.885
233
I-1-02-ii
19.982.805
20.582.290
20.981.946
21.381.602
234
I-1-02-iii
24.629.969
25.368.869
25.861.468
26.354.067
235
I-1-03-i
9.444.543
9.727.879
9.916.770
10.105.661
236
I-1-03-ii
12.945.372
13.333.733
13.592.641
13.851.548
237
I-1-03-iii
18.986.546
19.556.142
19.935.873
20.315.604
238
I-1-04-i
15.498.358
15.963.308
16.273.275
16.583.243
239
I-1-04-ii
19.907.915
20.505.153
20.903.311
21.301.470
240
I-1-04-iii
42.439.542
43.712.728
44.561.519
45.410.310
241
I-1-05-i
20.502.194
21.117.260
21.527.304
21.937.348
242
I-1-05-ii
24.602.633
25.340.712
25.832.765
26.324.817
243
I-1-05-iii
33.853.068
34.868.660
35.545.721
36.222.783
244
I-1-06-i
12.869.872
13.255.969
13.513.366
13.770.763
245
I-1-06-ii
16.841.119
17.346.353
17.683.175
18.019.997
246
I-1-06-iii
18.589.840
19.147.535
19.519.332
19.891.128
16.924.857
17.432.602
17.771.100
18.109.597
20.880.249
21.506.656
21.924.261
22.341.866
22.780.216
23.463.622
23.919.227
24.374.831
3.219.520
3.316.106
3.380.496
3.444.887
3.579.785
3.687.178
3.758.774
3.830.370
4.763.602
4.906.511
5.001.783
5.097.055
8.229.574
8.476.461
8.641.053
8.805.644
11.101.127
11.434.161
11.656.183
11.878.206
247
I-1-07-i
248
I-1-07-ii
249
I-1-07-iii
250
I-1-11-i
251
I-1-11-ii
252
I-1-11-iii
253
I-1-12-i
254
I-1-12-ii

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
KATETERISASI RINGAN
KATETERISASI SEDANG
KATETERISASI BERAT
RINGAN
SEDANG
BERAT

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
- 878 No
Kode
INA-CBG
255
I-1-12-iii
256
I-1-13-i
257
I-1-13-ii
258
I-1-13-iii
259
I-1-14-i
260
I-1-14-ii
261
I-1-14-iii
262
I-1-15-i
263
264
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
15.159.742
15.614.534
15.917.729
16.220.924
5.027.163
5.177.978
5.278.521
5.379.065
5.652.605
5.822.183
5.935.235
6.048.287
12.310.136
12.679.440
12.925.643
13.171.846
15.946.151
16.424.536
16.743.459
17.062.382
19.818.788
20.413.351
20.809.727
21.206.103
25.969.446
26.748.529
27.267.918
27.787.307
5.074.539
5.226.775
5.328.266
5.429.756
I-1-15-ii
9.296.904
9.575.811
9.761.749
9.947.687
I-1-15-iii
16.042.320
16.523.590
16.844.436
17.165.283
6.834.065
7.039.087
7.175.768
7.312.449
17.768.568
18.301.625
18.656.997
19.012.368
20.495.608
21.110.476
21.520.388
21.930.300
2.918.728
3.006.290
3.064.665
3.123.039
6.045.745
6.227.117
6.348.032
6.468.947
35.049.551
36.101.037
36.802.028
37.503.019
4.611.505
4.749.851
4.842.081
4.934.311
7.767.223
8.000.240
8.155.584
8.310.929
14.971.535
15.420.681
15.720.112
16.019.543
7.753.282
7.985.880
8.140.946
8.296.012
16.128.393
16.612.245
16.934.812
17.257.380
24.993.151
25.742.946
26.242.809
26.742.672
13.884.806
14.301.350
14.579.046
14.856.742
17.898.038
18.434.979
18.792.940
19.150.900
21.525.633
22.171.402
22.601.914
23.032.427

KOMPLEKS BERAT
KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

DARAH VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
265
I-1-16-i
266
I-1-16-ii
267
I-1-16-iii
268
I-1-17-i
269
I-1-17-ii
270
I-1-17-iii
271
I-1-20-i
272
I-1-20-ii
273
I-1-20-iii
274
I-1-30-i
275
I-1-30-ii
276
I-1-30-iii
277
I-1-40-i
278
I-1-40-ii
279
I-1-40-iii
280
I-4-10-i
4.038.105
4.159.248
4.240.010
4.320.772
281
I-4-10-ii
6.376.240
6.567.528
6.695.052
6.822.577
282
I-4-10-iii
9.198.283
9.474.231
9.658.197
9.842.163
283
I-4-11-i
4.129.430
4.253.313
4.335.901
4.418.490
- 879 No
Kode
INA-CBG
284
I-4-11-ii
285
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.804.949
4.949.098
5.045.197
5.141.296
I-4-11-iii
7.796.018
8.029.898
8.185.819
8.341.739
286
I-4-12-i
4.193.910
4.319.727
4.403.605
4.487.484
287
I-4-12-ii
5.984.698
6.164.239
6.283.932
6.403.626
288
I-4-12-iii
7.260.280
7.478.088
7.623.294
7.768.500
289
I-4-13-i
3.767.284
3.880.303
3.955.648
4.030.994
290
I-4-13-ii
5.473.095
5.637.288
5.746.750
5.856.212
291
I-4-13-iii
9.007.308
9.277.528
9.457.674
9.637.820
292
I-4-14-i
2.342.903
2.413.190
2.460.048
2.506.906
293
I-4-14-ii
2.741.543
2.823.789
2.878.620
2.933.451
294
I-4-14-iii
4.248.479
4.375.933
4.460.903
4.545.873
295
I-4-15-i
2.562.640
2.639.519
2.690.772
2.742.024
296
I-4-15-ii
4.934.569
5.082.606
5.181.298
5.279.989
297
I-4-15-iii
5.624.222
5.792.948
5.905.433
6.017.917
298
I-4-16-i
1.995.310
2.055.170
2.095.076
2.134.982
299
I-4-16-ii
3.200.208
3.296.214
3.360.218
3.424.222
300
I-4-16-iii
4.017.668
4.138.198
4.218.551
4.298.905
301
I-4-17-i
HIPERTENSI RINGAN
2.313.754
2.383.166
2.429.441
2.475.716
302
I-4-17-ii
HIPERTENSI SEDANG
3.156.381
3.251.073
3.314.200
3.377.328
303
I-4-17-iii
HIPERTENSI BERAT
3.689.176
3.799.851
3.873.635
3.947.418
304
I-4-18-i
3.407.494
3.509.719
3.577.869
3.646.019
305
I-4-18-ii
5.220.053
5.376.655
5.481.056
5.585.457
306
I-4-18-iii
7.037.469
7.248.593
7.389.342
7.530.091
307
I-4-19-i
2.666.811
2.746.815
2.800.152
2.853.488
308
I-4-19-ii
4.329.181
4.459.057
4.545.640
4.632.224
309
I-4-19-iii
4.958.939
5.107.708
5.206.886
5.306.065
310
I-4-20-i
3.236.553
3.333.650
3.398.381
3.463.112
311
I-4-20-ii
3.728.751
3.840.613
3.915.188
3.989.763
312
I-4-20-iii
4.948.673
5.097.133
5.196.106
5.295.080
313
I-4-21-i
4.304.092
4.433.214
4.519.296
4.605.378
314
I-4-21-ii
5.369.075
5.530.147
5.637.529
5.744.910
315
I-4-21-iii
7.324.557
7.544.294
7.690.785
7.837.276
316
I-4-22-i
2.082.145
2.144.609
2.186.252
2.227.895

VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT


RINGAN
SEDANG
KONGENITAL BERAT
RINGAN
SEDANG
BERAT
- 880 No
Kode
INA-CBG
317
I-4-22-ii
318
I-4-22-iii
319
I-4-23-i
320
I-4-23-ii
321
I-4-23-iii
322
I-4-24-i
323
I-4-24-ii
324
I-4-24-iii
325
J-1-01-i
326
J-1-01-ii
327
J-1-01-iii
328
J-1-02-i
329
J-1-02-ii
330
J-1-02-iii
331
J-1-10-i
332
J-1-10-ii
333
J-1-10-iii
334
J-1-20-i
335
J-1-20-ii
336
J-1-20-iii
337
J-1-30-i
338
J-1-30-ii
339
J-1-30-iii
340
J-4-10-i
341
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.399.254
2.471.232
2.519.217
2.567.202
3.500.446
3.605.460
3.675.469
3.745.478
1.593.223
1.641.019
1.672.884
1.704.748
1.956.110
2.014.794
2.053.916
2.093.038
3.822.061
3.936.723
4.013.164
4.089.605
2.530.559
2.606.476
2.657.087
2.707.698
6.318.106
6.507.650
6.634.012
6.760.374
7.988.104
8.227.747
8.387.509
8.547.272
20.387.939
20.999.577
21.407.336
21.815.094
21.780.361
22.433.772
22.869.379
23.304.986
37.211.875
38.328.231
39.072.468
39.816.706
10.421.910
10.734.567
10.943.005
11.151.444
11.164.642
11.499.582
11.722.874
11.946.167
16.498.160
16.993.105
17.323.068
17.653.031
4.066.780
4.188.783
4.270.119
4.351.455
9.822.751
10.117.434
10.313.889
10.510.344
14.852.810
15.298.394
15.595.450
15.892.506
3.452.099
3.555.662
3.624.704
3.693.746
5.112.289
5.265.657
5.367.903
5.470.149
6.707.758
6.908.990
7.043.146
7.177.301
2.370.358
2.441.469
2.488.876
2.536.283
10.172.127
10.477.291
10.680.733
10.884.176
27.745.491
28.577.856
29.132.766
29.687.676
2.054.307
2.115.936
2.157.022
2.198.108
J-4-10-ii
2.937.412
3.025.534
3.084.282
3.143.030
342
J-4-10-iii
4.443.865
4.577.181
4.666.058
4.754.936
343
J-4-11-i
1.725.885
1.777.661
1.812.179
1.846.697
344
J-4-11-ii
2.402.392
2.474.464
2.522.512
2.570.560
345
J-4-11-iii
3.442.689
3.545.970
3.614.824
3.683.677
346
J-4-12-i
EMBOLI PARU RINGAN
1.981.930
2.041.388
2.081.026
2.120.665
347
J-4-12-ii
EMBOLI PARU SEDANG
2.566.531
2.643.527
2.694.858
2.746.189

RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
- 881 No
Kode
INA-CBG
348
J-4-12-iii
349
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
EMBOLI PARU BERAT
3.427.343
3.530.164
3.598.710
3.667.257
J-4-13-i
4.065.564
4.187.531
4.268.842
4.350.154
350
J-4-13-ii
5.976.379
6.155.671
6.275.198
6.394.726
351
J-4-13-iii
9.716.698
10.008.199
10.202.533
10.396.867
352
J-4-14-i
TUMOR PARU RINGAN
2.770.554
2.853.670
2.909.081
2.964.492
353
J-4-14-ii
TUMOR PARU SEDANG
4.641.056
4.780.288
4.873.109
4.965.930
354
J-4-14-iii
TUMOR PARU BERAT
5.517.980
5.683.520
5.793.879
5.904.239
355
J-4-15-i
2.425.514
2.498.280
2.546.790
2.595.300
356
J-4-15-ii
3.415.268
3.517.726
3.586.032
3.654.337
357
J-4-15-iii
4.291.722
4.420.473
4.506.308
4.592.142
358
J-4-16-i
1.656.786
1.706.489
1.739.625
1.772.761
359
J-4-16-ii
2.851.406
2.936.948
2.993.977
3.051.005
360
J-4-16-iii
4.672.136
4.812.300
4.905.742
4.999.185
361
J-4-17-i
1.985.753
2.045.326
2.085.041
2.124.756
362
J-4-17-ii
2.695.244
2.776.101
2.830.006
2.883.911
363
J-4-17-iii
4.322.937
4.452.625
4.539.084
4.625.543
364
J-4-18-i
1.345.818
1.386.193
1.413.109
1.440.026
365
J-4-18-ii
2.059.102
2.120.875
2.162.057
2.203.239
366
J-4-18-iii
2.153.309
2.217.909
2.260.975
2.304.041
367
J-4-19-i
2.516.442
2.591.935
2.642.264
2.692.593
368
J-4-19-ii
3.415.243
3.517.700
3.586.005
3.654.310
369
J-4-19-iii
4.881.898
5.028.355
5.125.993
5.223.631
370
J-4-20-i
2.777.836
2.861.171
2.916.728
2.972.285
371
J-4-20-ii
3.679.128
3.789.502
3.863.085
3.936.667
372
J-4-20-iii
7.333.488
7.553.492
7.700.162
7.846.832
373
J-4-21-i
1.546.207
1.592.593
1.623.517
1.654.441
374
J-4-21-ii
3.445.064
3.548.416
3.617.317
3.686.218
375
J-4-21-iii
4.806.359
4.950.550
5.046.677
5.142.804
376
K-1-10-i
3.452.099
3.555.662
3.624.704
3.693.746
377
K-1-10-ii
6.480.207
6.674.613
6.804.217
6.933.821
378
K-1-10-iii
7.589.438
7.817.121
7.968.910
8.120.699
379
K-1-11-i
3.992.633
4.112.412
4.192.264
4.272.117
380
K-1-11-ii
5.241.845
5.399.100
5.503.937
5.608.774

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT

USUS BESAR (RINGAN)
USUS BESAR (SEDANG)
USUS BESAR (BERAT)
- 882 No
Kode
INA-CBG
381
K-1-11-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
13.302.771
13.701.854
13.967.909
14.233.965
2.147.731
2.212.163
2.255.117
2.298.072
2.799.158
2.883.132
2.939.116
2.995.099
5.568.113
5.735.157
5.846.519
5.957.881
382
K-1-12-i
383
K-1-12-ii
384
K-1-12-iii
385
K-1-13-i
2.439.528
2.512.714
2.561.504
2.610.295
386
K-1-13-ii
4.261.155
4.388.989
4.474.212
4.559.435
387
K-1-13-iii
4.557.151
4.693.866
4.785.009
4.876.152
3.942.421
4.060.694
4.139.542
4.218.391
4.630.821
4.769.745
4.862.362
4.954.978
10.926.662
11.254.462
11.472.995
11.691.529

RINGAN
SEDANG
BERAT
388
K-1-14-i
389
K-1-14-ii
390
K-1-14-iii
391
K-1-20-i
7.649.454
7.878.938
8.031.927
8.184.916
392
K-1-20-ii
10.676.621
10.996.919
11.210.452
11.423.984
393
K-1-20-iii
21.876.370
22.532.661
22.970.189
23.407.716
394
K-1-30-i
5.035.251
5.186.309
5.287.014
5.387.719
395
K-1-30-ii
6.904.198
7.111.324
7.249.408
7.387.492
396
K-1-30-iii
14.463.083
14.896.975
15.186.237
15.475.498
397
K-1-40-i
5.058.518
5.210.273
5.311.444
5.412.614
398
K-1-40-ii
5.566.396
5.733.388
5.844.716
5.956.044
399
K-1-40-iii
9.231.332
9.508.272
9.692.899
9.877.526
400
K-1-50-i
3.858.429
3.974.181
4.051.350
4.128.519
401
K-1-50-ii
4.996.847
5.146.752
5.246.689
5.346.626
402
K-1-50-iii
PROSEDUR ANAL BERAT
7.094.194
7.307.020
7.448.904
7.590.787
403
K-4-10-i
2.922.482
3.010.157
3.068.606
3.127.056
404
K-4-10-ii
3.496.921
3.601.829
3.671.768
3.741.706
405
K-4-10-iii
11.782.373
12.135.844
12.371.492
12.607.139
406
K-4-11-i
1.443.758
1.487.071
1.515.946
1.544.821
407
K-4-11-ii
2.343.140
2.413.434
2.460.297
2.507.160
408
K-4-11-iii
3.929.906
4.047.803
4.126.401
4.204.999
409
K-4-12-i
1.474.083
1.518.305
1.547.787
1.577.269
410
K-4-12-ii
2.574.892
2.652.138
2.703.636
2.755.134
411
K-4-12-iii
5.664.871
5.834.817
5.948.114
6.061.412
412
K-4-13-i

(RINGAN)
2.027.603
2.088.432
2.128.984
2.169.536

(RINGAN)
(SEDANG)
(BERAT)
- 883 No
Kode
INA-CBG
413
K-4-13-ii
414
K-4-13-iii
415
K-4-14-i
416
K-4-14-ii
417
K-4-14-iii
418
K-4-15-i
419
K-4-15-ii
420
K-4-15-iii
421
K-4-16-i
422
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.600.774
2.678.797
2.730.812
2.782.828
4.198.896
4.324.863
4.408.840
4.492.818
1.670.019
1.720.120
1.753.520
1.786.920
2.241.734
2.308.986
2.353.820
2.398.655
3.935.771
4.053.844
4.132.559
4.211.275
1.763.801
1.816.715
1.851.991
1.887.267
3.187.885
3.283.521
3.347.279
3.411.037
4.474.043
4.608.264
4.697.745
4.787.226
1.773.238
1.826.435
1.861.899
1.897.364
K-4-16-ii
2.348.165
2.418.610
2.465.573
2.512.536
423
K-4-16-iii
3.155.645
3.250.314
3.313.427
3.376.540
424
K-4-17-i
1.281.320
1.319.759
1.345.386
1.371.012
425
K-4-17-ii
2.514.628
2.590.067
2.640.359
2.690.652
426
K-4-17-iii
3.056.914
3.148.622
3.209.760
3.270.898
427
K-4-18-i
1.717.893
1.769.430
1.803.787
1.838.145
428
K-4-18-ii
2.675.597
2.755.865
2.809.377
2.862.889
429
K-4-18-iii
3.111.100
3.204.433
3.266.655
3.328.877
430
L-1-20-i
17.637.073
18.166.185
18.518.927
18.871.668
431
L-1-20-ii
18.165.170
18.710.125
19.073.429
19.436.732
432
L-1-20-iii
25.459.232
26.223.009
26.732.194
27.241.378
433
L-1-30-i
6.041.174
6.222.409
6.343.232
6.464.056
434
L-1-30-ii
11.587.529
11.935.155
12.166.906
12.398.656
435
L-1-30-iii
12.221.228
12.587.864
12.832.289
13.076.714
436
L-1-40-i
3.230.029
3.326.930
3.391.530
3.456.131
437
L-1-40-ii
6.904.198
7.111.324
7.249.408
7.387.492
438
L-1-40-iii
9.904.358
10.201.488
10.399.576
10.597.663
439
L-1-50-i
4.315.124
4.444.578
4.530.880
4.617.183
440
L-1-50-ii
7.767.223
8.000.240
8.155.584
8.310.929
441
L-1-50-iii
9.391.672
9.673.422
9.861.256
10.049.089
442
L-4-10-i
2.129.689
2.193.579
2.236.173
2.278.767
443
L-4-10-ii
2.964.558
3.053.495
3.112.786
3.172.077

(SEDANG)
RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
- 884 No
Kode
INA-CBG
444
L-4-10-iii
445
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
6.101.385
6.284.427
6.406.455
6.528.482
L-4-11-i
2.445.185
2.518.540
2.567.444
2.616.347
446
L-4-11-ii
3.349.860
3.450.356
3.517.353
3.584.350
447
L-4-11-iii
9.084.402
9.356.934
9.538.622
9.720.310
448
L-4-12-i
2.413.828
2.486.243
2.534.519
2.582.796
449
L-4-12-ii
3.793.175
3.906.971
3.982.834
4.058.698
450
L-4-12-iii
6.142.912
6.327.199
6.450.057
6.572.916
451
L-4-13-i
1.622.689
1.671.370
1.703.824
1.736.278
452
L-4-13-ii
1.871.056
1.927.188
1.964.609
2.002.030
453
L-4-13-iii
2.806.731
2.890.933
2.947.067
3.003.202
454
L-4-14-i
1.478.761
1.523.124
1.552.699
1.582.274
455
L-4-14-ii
2.197.820
2.263.755
2.307.711
2.351.667
456
L-4-14-iii
4.042.100
4.163.363
4.244.205
4.325.047
457
M-1-01-i
6.309.827
6.499.122
6.625.318
6.751.515
458
M-1-01-ii
7.042.788
7.254.071
7.394.927
7.535.783
459
M-1-01-iii
9.893.208
10.190.005
10.387.869
10.585.733
460
M-1-02-i
5.951.300
6.129.839
6.248.865
6.367.891
461
M-1-02-ii
9.770.904
10.064.031
10.259.449
10.454.867
462
M-1-02-iii
16.789.212
17.292.889
17.628.673
17.964.457
463
M-1-03-i
11.219.323
11.555.902
11.780.289
12.004.675
464
M-1-03-ii
13.129.888
13.523.785
13.786.383
14.048.981
465
M-1-03-iii
17.087.120
17.599.734
17.941.476
18.283.218
466
M-1-04-i
3.925.894
4.043.671
4.122.189
4.200.707
467
M-1-04-ii
5.032.956
5.183.945
5.284.604
5.385.263
468
M-1-04-iii
6.297.796
6.486.730
6.612.686
6.738.641
469
M-1-05-i
6.115.790
6.299.263
6.421.579
6.543.895
470
M-1-05-ii
7.068.214
7.280.261
7.421.625
7.562.989
471
M-1-05-iii
12.039.094
12.400.267
12.641.048
12.881.830
472
M-1-07-i
5.069.461
5.221.545
5.322.934
5.424.323
473
M-1-07-ii
6.791.494
6.995.239
7.131.069
7.266.898
474
M-1-07-iii
13.834.917
14.249.964
14.526.663
14.803.361
475
M-1-10-i
4.219.230
4.345.807
4.430.192
4.514.576


TULANG WAJAH RINGAN
- 885 No
Kode
INA-CBG
476
M-1-10-ii
477
M-1-10-iii
478
M-1-20-i
479
M-1-20-ii
480
M-1-20-iii
481
M-1-30-i
482
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
15.672.528
16.142.704
16.456.154
16.769.605
18.273.045
18.821.236
19.186.697
19.552.158
4.173.909
4.299.126
4.382.604
4.466.082
5.957.880
6.136.616
6.255.774
6.374.932
11.580.820
11.928.245
12.159.861
12.391.477
2.496.621
2.571.520
2.621.452
2.671.385
M-1-30-ii
5.158.655
5.313.414
5.416.588
5.519.761
483
M-1-30-iii
PROSEDUR KAKI BERAT
7.695.625
7.926.494
8.080.407
8.234.319
484
M-1-40-i
2.465.415
2.539.377
2.588.685
2.637.994
485
M-1-40-ii
4.057.960
4.179.699
4.260.858
4.342.017
486
M-1-40-iii
6.041.174
6.222.409
6.343.232
6.464.056
487
M-1-50-i
3.340.921
3.441.149
3.507.967
3.574.786
488
M-1-50-ii
6.041.174
6.222.409
6.343.232
6.464.056
489
M-1-50-iii
6.904.198
7.111.324
7.249.408
7.387.492
490
M-1-60-i
2.521.341
2.596.982
2.647.408
2.697.835
491
M-1-60-ii
5.047.742
5.199.174
5.300.129
5.401.084
492
M-1-60-iii
8.784.856
9.048.402
9.224.099
9.399.796
493
M-1-70-i
3.377.584
3.478.911
3.546.463
3.614.015
494
M-1-70-ii
6.891.943
7.098.702
7.236.541
7.374.379
495
M-1-70-iii
11.110.645
11.443.965
11.666.178
11.888.391
496
M-1-80-i
2.721.418
2.803.061
2.857.489
2.911.918
497
M-1-80-ii
4.114.228
4.237.655
4.319.939
4.402.224
498
M-1-80-iii
9.472.019
9.756.179
9.945.620
10.135.060
499
M-4-10-i
1.465.602
1.509.570
1.538.882
1.568.195
500
M-4-10-ii
2.629.638
2.708.527
2.761.120
2.813.712
501
M-4-10-iii
FRAKTUR FEMUR BERAT
5.583.897
5.751.414
5.863.092
5.974.770
502
M-4-11-i
2.280.973
2.349.402
2.395.021
2.440.641
503
M-4-11-ii
5.232.892
5.389.878
5.494.536
5.599.194
504
M-4-11-iii
9.288.260
9.566.908
9.752.673
9.938.438
505
M-4-12-i
1.281.320
1.319.759
1.345.386
1.371.012
506
M-4-12-ii
2.331.360
2.401.301
2.447.928
2.494.555

TULANG WAJAH SEDANG
TULANG WAJAH BERAT

RINGAN
SEDANG
BERAT

SELAIN KAKI (BERAT)

PANGGUL RINGAN
PANGGUL SEDANG
PANGGUL BERAT
PELVIS RINGAN
PELVIS SEDANG
- 886 No
Kode
INA-CBG
507
M-4-12-iii
508
M-4-13-i
509
M-4-13-ii
510
M-4-13-iii
511
M-4-14-i
512
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.125.279
5.279.038
5.381.543
5.484.049
3.181.745
3.277.197
3.340.832
3.404.467
3.561.983
3.668.843
3.740.082
3.811.322
9.464.894
9.748.840
9.938.138
10.127.436
2.562.640
2.639.519
2.690.772
2.742.024
M-4-14-ii
4.475.147
4.609.401
4.698.904
4.788.407
513
M-4-14-iii
OSTEOMIELITIS BERAT
5.808.178
5.982.424
6.098.587
6.214.751
514
M-4-15-i
2.150.567
2.215.084
2.258.095
2.301.107
515
M-4-15-ii
2.668.244
2.748.291
2.801.656
2.855.021
516
M-4-15-iii
5.998.826
6.178.790
6.298.767
6.418.743
517
M-4-16-i
2.148.490
2.212.944
2.255.914
2.298.884
518
M-4-16-ii
3.139.615
3.233.803
3.296.596
3.359.388
519
M-4-16-iii
6.409.473
6.601.758
6.729.947
6.858.137
520
M-4-17-i
1.840.698
1.895.918
1.932.732
1.969.546
521
M-4-17-ii
2.413.968
2.486.387
2.534.666
2.582.945
522
M-4-17-iii
3.312.115
3.411.478
3.477.720
3.543.963
523
M-4-18-i
2.525.271
2.601.029
2.651.535
2.702.040
524
M-4-18-ii
3.109.805
3.203.099
3.265.295
3.327.491
525
M-4-18-iii
4.282.713
4.411.194
4.496.848
4.582.503
526
M-4-19-i
1.877.573
1.933.901
1.971.452
2.009.004
527
M-4-19-ii
3.005.542
3.095.709
3.155.820
3.215.930
528
M-4-19-iii
4.795.938
4.939.816
5.035.734
5.131.653
529
M-4-20-i
1.399.750
1.441.742
1.469.737
1.497.732
530
M-4-20-ii
1.921.980
1.979.639
2.018.079
2.056.518
531
M-4-20-iii
2.130.007
2.193.907
2.236.507
2.279.107
532
M-4-21-i
1.341.304
1.381.543
1.408.370
1.435.196
533
M-4-21-ii
2.249.609
2.317.097
2.362.090
2.407.082
534
M-4-21-iii
4.644.784
4.784.128
4.877.024
4.969.919
535
N-1-01-i
3.501.809
3.606.864
3.676.900
3.746.936
536
N-1-01-ii
4.736.118
4.878.202
4.972.924
5.067.646
537
N-1-01-iii
10.041.979
10.343.239
10.544.078
10.744.918

PELVIS BERAT

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
RINGAN
SEDANG
BERAT
ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
- 887 No
Kode
INA-CBG
538
N-1-11-i
539
N-1-11-ii
540
N-1-11-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
6.041.174
6.222.409
6.343.232
6.464.056
8.701.082
8.962.115
9.136.136
9.310.158
13.808.397
14.222.649
14.498.817
14.774.985
2.589.074
2.666.747
2.718.528
2.770.310
8.101.953
8.345.011
8.507.050
8.669.089
14.766.313
15.209.303
15.504.629
15.799.955
541
N-1-12-i
542
N-1-12-ii
543
N-1-12-iii
544
N-1-20-i
4.715.125
4.856.579
4.950.881
5.045.183
545
N-1-20-ii
9.348.416
9.628.869
9.815.837
10.002.805
546
N-1-20-iii
10.693.741
11.014.553
11.228.428
11.442.302
547
N-1-30-i
5.609.473
5.777.757
5.889.947
6.002.136
548
N-1-30-ii
8.524.294
8.780.023
8.950.509
9.120.995
549
N-1-30-iii
9.395.686
9.677.557
9.865.471
10.053.384
550
N-1-40-i
5.054.684
5.206.325
5.307.418
5.408.512
551
N-1-40-ii
6.851.805
7.057.359
7.194.395
7.331.431
552
N-1-40-iii
7.968.847
8.207.912
8.367.289
8.526.666
553
N-4-10-i
1.971.508
2.030.653
2.070.083
2.109.513
554
N-4-10-ii
2.884.779
2.971.322
3.029.018
3.086.713
555
N-4-10-iii
5.684.971
5.855.520
5.969.220
6.082.919
556
N-4-11-i
1.649.833
1.699.328
1.732.325
1.765.321
557
N-4-11-ii
2.788.178
2.871.824
2.927.587
2.983.351
558
N-4-11-iii
3.190.586
3.286.304
3.350.116
3.413.927
559
N-4-12-i
1.595.312
1.643.171
1.675.078
1.706.984
560
N-4-12-ii
2.242.168
2.309.433
2.354.276
2.399.120
561
N-4-12-iii
3.524.084
3.629.806
3.700.288
3.770.770
562
N-4-13-i
BATU URIN RINGAN
2.273.835
2.342.050
2.387.526
2.433.003
563
N-4-13-ii
BATU URIN SEDANG
2.741.389
2.823.631
2.878.459
2.933.287
564
N-4-13-iii
BATU URIN BERAT
6.751.290
6.953.829
7.088.855
7.223.880
565
N-4-14-i
1.121.034
1.154.665
1.177.086
1.199.507
566
N-4-14-ii
1.726.252
1.778.040
1.812.565
1.847.090
567
N-4-14-iii
2.799.430
2.883.413
2.939.402
2.995.391

URIN BAWAH RINGAN
URIN BAWAH SEDANG
URIN BAWAH BERAT
RINGAN
SEDANG
BERAT
GINJAL RINGAN
GINJAL SEDANG
GINJAL BERAT

(RINGAN)
(SEDANG)
(BERAT)
- 888 No
Kode
INA-CBG
568
N-4-15-i
569
N-4-15-ii
570
N-4-15-iii
571
N-4-16-i
572
N-4-16-ii
573
N-4-16-iii
574
O-6-10-i
575
O-6-10-ii
576
O-6-10-iii
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
584
585
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.214.798
2.281.242
2.325.538
2.369.834
3.039.392
3.130.573
3.191.361
3.252.149
3.468.494
3.572.549
3.641.919
3.711.289
2.224.362
2.291.093
2.335.580
2.380.067
2.870.485
2.956.599
3.014.009
3.071.418
5.725.149
5.896.903
6.011.406
6.125.909
2.766.694
2.849.695
2.905.029
2.960.363
3.071.452
3.163.596
3.225.025
3.286.454
3.785.070
3.898.622
3.974.323
4.050.025
1.746.651
1.799.050
1.833.983
1.868.916
2.845.807
2.931.181
2.988.097
3.045.013
4.822.759
4.967.442
5.063.897
5.160.352
1.931.659
1.989.608
2.028.242
2.066.875
2.319.917
2.389.515
2.435.913
2.482.311
2.914.644
3.002.083
3.060.376
3.118.669
1.368.815
1.409.879
1.437.256
1.464.632
O-6-13-ii
1.599.112
1.647.085
1.679.068
1.711.050
O-6-13-iii
1.988.707
2.048.369
2.088.143
2.127.917
32.518.364
33.493.915
34.144.282
34.794.649
40.236.388
41.443.480
42.248.208
43.052.935
47.226.240
48.643.028
49.587.553
50.532.077
52.466.831
54.040.836
55.090.172
56.139.509
60.184.855
61.990.401
63.194.098
64.397.795
68.765.500
70.828.466
72.203.776
73.579.086
2.157.562
2.222.289
2.265.440
2.308.591
3.213.609
3.310.017
3.374.289
3.438.561
5.840.338
6.015.548
6.132.355
6.249.162
25.918.164
26.695.709
27.214.072
27.732.435
33.636.188
34.645.274
35.317.998
35.990.721
586
P-8-01-i
587
P-8-01-ii
588
P-8-01-iii
589
P-8-02-i
590
P-8-02-ii
591
P-8-02-iii
592
P-8-03-i
593
P-8-03-ii
594
P-8-03-iii
595
P-8-04-i
596
P-8-04-ii

SALURAN URIN RINGAN
SALURAN URIN SEDANG
SALURAN URIN BERAT
RINGAN
SEDANG
BERAT
&KURET RINGAN
KURET SEDANG
KURET BERAT

- 889 No
Kode
INA-CBG
597
P-8-04-iii
598
P-8-05-i
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii
603
P-8-06-iii
604
P-8-07-i
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
614
P-8-11-ii
615
P-8-11-iii
616
P-8-12-i
617
P-8-12-ii
618
P-8-12-iii
619
P-8-13-i
620
P-8-13-ii
621
P-8-13-iii
622
P-8-14-i
623
P-8-14-ii
624
P-8-14-iii
Deskripsi (INA-CBG)
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
RINGAN
SEDANG
BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
48.225.828
49.672.602
50.637.119
51.601.636
14.093.457
14.516.261
14.798.130
15.079.999
19.975.575
20.574.843
20.974.354
21.373.866
29.431.329
30.314.269
30.902.895
31.491.522
1.973.602
2.032.810
2.072.282
2.111.754
5.178.149
5.333.493
5.437.056
5.540.619
9.493.273
9.778.071
9.967.937
10.157.802
3.745.328
3.857.688
3.932.595
4.007.501
9.248.594
9.526.052
9.711.024
9.895.996
12.436.173
12.809.258
13.057.981
13.306.705
2.944.381
3.032.712
3.091.600
3.150.488
4.179.963
4.305.362
4.388.961
4.472.560
5.337.349
5.497.470
5.604.217
5.710.964
1.826.691
1.881.491
1.918.025
1.954.559
2.646.227
2.725.614
2.778.538
2.831.463
5.195.324
5.351.183
5.455.090
5.558.996
1.801.500
1.855.545
1.891.575
1.927.605
10.953.004
11.281.594
11.500.654
11.719.714
11.182.471
11.517.945
11.741.595
11.965.244
2.427.152
2.499.966
2.548.509
2.597.052
3.773.800
3.887.014
3.962.490
4.037.966
4.452.286
4.585.854
4.674.900
4.763.945
1.254.483
1.292.117
1.317.207
1.342.297
2.321.411
2.391.053
2.437.481
2.483.910
3.471.918
3.576.076
3.645.514
3.714.952
2.292.071
2.360.833
2.406.674
2.452.516
4.679.760
4.820.153
4.913.748
5.007.343
5.133.679
5.287.690
5.390.363
5.493.037
- 890 No
Kode
INA-CBG
625
P-8-15-i
626
P-8-15-ii
627
P-8-15-iii
628
P-8-16-i
629
P-8-16-ii
630
P-8-16-iii
631
P-8-17-i
632
P-8-17-ii
633
P-8-17-iii
634
S-4-10-i
635
S-4-10-ii
636
S-4-10-iii
637
S-4-11-i
638
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.723.709
1.775.420
1.809.894
1.844.368
3.445.240
3.548.598
3.617.502
3.686.407
4.046.968
4.168.377
4.249.317
4.330.256
1.560.364
1.607.175
1.638.382
1.669.589
2.213.443
2.279.846
2.324.115
2.368.384
2.873.157
2.959.352
3.016.815
3.074.278
1.027.967
1.058.806
1.079.365
1.099.925
3.420.769
3.523.392
3.591.808
3.660.223
6.904.604
7.111.742
7.249.835
7.387.927
1.281.320
1.319.759
1.345.386
1.371.012
1.601.650
1.649.699
1.681.732
1.713.765
2.081.870
2.144.326
2.185.963
2.227.601
800.825
824.850
840.866
856.883
S-4-11-ii
1.281.320
1.319.759
1.345.386
1.371.012
639
S-4-11-iii
1.971.919
2.031.077
2.070.515
2.109.954
640
S-4-12-i
987.679
1.017.309
1.037.062
1.056.816
641
S-4-12-ii
1.350.890
1.391.417
1.418.435
1.445.452
642
S-4-12-iii
2.584.384
2.661.916
2.713.603
2.765.291
643
S-4-13-i
1.535.011
1.581.062
1.611.762
1.642.462
644
S-4-13-ii
2.528.682
2.604.543
2.655.116
2.705.690
645
S-4-13-iii
4.899.228
5.046.205
5.144.189
5.242.174
646
S-4-14-i
788.544
812.201
827.972
843.743
647
S-4-14-ii
1.675.133
1.725.387
1.758.890
1.792.392
648
S-4-14-iii
3.176.649
3.271.948
3.335.481
3.399.014
649
S-4-15-i
596.383
614.275
626.203
638.130
650
S-4-15-ii
1.125.579
1.159.346
1.181.858
1.204.369
651
S-4-15-iii
1.457.886
1.501.623
1.530.780
1.559.938
652
S-4-16-i
LUKA BAKAR RINGAN
2.448.297
2.521.746
2.570.712
2.619.678
653
S-4-16-ii
LUKA BAKAR SEDANG
4.259.767
4.387.560
4.472.755
4.557.950
654
S-4-16-iii
LUKA BAKAR BERAT
7.606.474
7.834.669
7.986.798
8.138.928
1.608.263
1.656.511
1.688.676
1.720.841
1.872.988
1.929.177
1.966.637
2.004.097
655
S-4-17-i
656
S-4-17-ii

ASPIRASI RINGAN
ASPIRASI SEDANG
ASPIRASI BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT

PASIEN RINGAN
PASIEN SEDANG
PASIEN BERAT

- 891 No
Kode
INA-CBG
657
S-4-17-iii
658
T-1-10-i
659
T-1-10-ii
660
T-1-10-iii
661
T-4-10-i
662
T-4-10-ii
663
T-4-10-iii
664
T-4-11-i
665
T-4-11-ii
666
T-4-11-iii
667
T-4-12-i
668
T-4-12-ii
669
T-4-12-iii
670
U-1-10-i
671
672
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.893.314
2.980.114
3.037.980
3.095.846
1.660.171
1.709.976
1.743.180
1.776.383
2.229.497
2.296.382
2.340.972
2.385.562
4.056.182
4.177.868
4.258.991
4.340.115
545.325
561.684
572.591
583.497
1.039.268
1.070.446
1.091.231
1.112.017
1.510.814
1.556.138
1.586.354
1.616.571
718.176
739.722
754.085
768.449
1.130.205
1.164.111
1.186.715
1.209.320
1.820.428
1.875.040
1.911.449
1.947.858
1.181.942
1.217.400
1.241.039
1.264.677
1.761.124
1.813.957
1.849.180
1.884.402
2.712.172
2.793.537
2.847.780
2.902.024
1.205.381
1.241.543
1.265.650
1.289.758
U-1-10-ii
2.459.655
2.533.444
2.582.637
2.631.830
U-1-10-iii
10.621.286
10.939.924
11.152.350
11.364.776
5.178.149
5.333.493
5.437.056
5.540.619
6.904.198
7.111.324
7.249.408
7.387.492
15.602.740
16.070.823
16.382.877
16.694.932

DOKTER RINGAN
DOKTER SEDANG
DOKTER BERAT

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
673
U-1-11-i
674
U-1-11-ii
675
U-1-11-iii
676
U-1-12-i
4.256.472
4.384.166
4.469.296
4.554.425
677
U-1-12-ii
7.767.223
8.000.240
8.155.584
8.310.929
678
U-1-12-iii
10.085.886
10.388.463
10.590.181
10.791.899
679
U-1-13-i
3.452.099
3.555.662
3.624.704
3.693.746
680
U-1-13-ii
4.315.124
4.444.578
4.530.880
4.617.183
681
U-1-13-iii
7.510.474
7.735.789
7.885.998
8.036.208
2.562.097
2.638.960
2.690.202
2.741.444
3.144.208
3.238.534
3.301.418
3.364.303
3.725.975
3.837.754
3.912.274
3.986.793

682
U-1-14-i
683
U-1-14-ii
684
U-1-14-iii
685
U-1-15-i
1.504.817
1.549.962
1.580.058
1.610.154
686
U-1-15-ii
2.138.240
2.202.387
2.245.152
2.287.917
687
U-1-15-iii
4.213.488
4.339.893
4.424.163
4.508.432
- 892 No
Kode
INA-CBG
688
U-1-20-i
689
U-1-20-ii
690
U-1-20-iii
691
U-1-30-i
692
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.892.307
4.009.076
4.086.922
4.164.768
6.118.567
6.302.124
6.424.495
6.546.866
12.707.125
13.088.339
13.342.481
13.596.624
3.338.920
3.439.088
3.505.866
3.572.645
U-1-30-ii
4.507.542
4.642.769
4.732.919
4.823.070
693
U-1-30-iii
6.904.198
7.111.324
7.249.408
7.387.492
694
U-4-10-i
3.107.977
3.201.216
3.263.376
3.325.535
695
U-4-10-ii
7.791.046
8.024.777
8.180.598
8.336.419
696
U-4-10-iii
11.365.439
11.706.402
11.933.711
12.161.020
697
U-4-11-i
1.442.345
1.485.615
1.514.462
1.543.309
698
U-4-11-ii
1.921.980
1.979.639
2.018.079
2.056.518
699
U-4-11-iii
3.575.403
3.682.666
3.754.174
3.825.682
700
U-4-12-i
1.281.320
1.319.759
1.345.386
1.371.012
701
U-4-12-ii
2.009.211
2.069.488
2.109.672
2.149.856
702
U-4-12-iii
3.194.555
3.290.391
3.354.282
3.418.174
703
U-4-13-i
1.281.320
1.319.759
1.345.386
1.371.012
704
U-4-13-ii
1.463.431
1.507.334
1.536.603
1.565.871
705
U-4-13-iii
2.235.048
2.302.099
2.346.800
2.391.501
706
U-4-14-i
1.601.650
1.649.699
1.681.732
1.713.765
707
U-4-14-ii
1.921.980
1.979.639
2.018.079
2.056.518
708
U-4-14-iii
3.240.058
3.337.260
3.402.061
3.466.863
709
U-4-15-i
1.380.161
1.421.566
1.449.169
1.476.772
710
U-4-15-ii
1.817.616
1.872.144
1.908.496
1.944.849
711
U-4-15-iii
2.465.165
2.539.120
2.588.423
2.637.726
712
V-1-10-i
4.257.480
4.385.204
4.470.354
4.555.504
713
V-1-10-ii
4.832.614
4.977.592
5.074.245
5.170.897
714
V-1-10-iii
8.198.736
8.444.698
8.608.672
8.772.647
715
V-1-11-i
4.315.124
4.444.578
4.530.880
4.617.183
716
V-1-11-ii
4.815.751
4.960.223
5.056.538
5.152.853
717
V-1-11-iii
7.131.390
7.345.331
7.487.959
7.630.587
3.134.780
3.228.823
3.291.519
3.354.214
9.569.408
9.856.491
10.047.879
10.239.267
10.762.055
11.084.916
11.300.157
11.515.398
718
V-1-12-i
719
V-1-12-ii
720
V-1-12-iii


DAN TELINGA RINGAN
DAN TELINGA SEDANG
DAN TELINGA BERAT


KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

- 893 No
Kode
INA-CBG
721
V-1-13-i
722
V-1-13-ii
723
V-1-13-iii
724
V-1-14-i
725
V-1-14-ii
726
V-1-14-iii
727
V-1-15-i
728
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.751.310
4.893.849
4.988.876
5.083.902
9.028.853
9.299.718
9.480.295
9.660.872
10.356.298
10.666.987
10.874.113
11.081.239
5.727.759
5.899.592
6.014.147
6.128.703
8.330.535
8.580.451
8.747.062
8.913.673
11.271.539
11.609.685
11.835.116
12.060.547
2.589.074
2.666.747
2.718.528
2.770.310
V-1-15-ii
4.040.421
4.161.633
4.242.442
4.323.250
729
V-1-15-iii
6.722.404
6.924.076
7.058.524
7.192.972
730
V-4-10-i
4.348.196
4.478.642
4.565.606
4.652.570
731
V-4-10-ii
5.616.215
5.784.701
5.897.026
6.009.350
732
V-4-10-iii
10.733.573
11.055.580
11.270.251
11.484.923
733
V-4-11-i
2.211.221
2.277.557
2.321.782
2.366.006
734
V-4-11-ii
3.230.947
3.327.875
3.392.494
3.457.113
735
V-4-11-iii
5.330.848
5.490.774
5.597.391
5.704.008
736
W-1-01-i
6.502.072
6.697.134
6.827.175
6.957.217
737
W-1-01-ii
7.831.437
8.066.380
8.223.009
8.379.638
738
W-1-01-iii
14.180.267
14.605.675
14.889.281
15.172.886
739
W-1-10-i
1.726.050
1.777.831
1.812.352
1.846.873
740
W-1-10-ii
3.379.286
3.480.664
3.548.250
3.615.836
741
W-1-10-iii
5.527.439
5.693.262
5.803.811
5.914.360
742
W-1-11-i
1.880.839
1.937.264
1.974.881
2.012.498
743
W-1-11-ii
3.452.099
3.555.662
3.624.704
3.693.746
744
W-1-11-iii
5.178.149
5.333.493
5.437.056
5.540.619
745
W-1-12-i
1.709.025
1.760.296
1.794.476
1.828.657
746
W-1-12-ii
1.943.128
2.001.422
2.040.285
2.079.147
747
W-1-12-iii
2.984.890
3.074.437
3.134.135
3.193.833
748
W-1-13-i
1.527.485
1.573.309
1.603.859
1.634.408
749
W-1-13-ii
1.658.408
1.708.160
1.741.328
1.774.497
750
W-1-13-iii
2.227.548
2.294.374
2.338.925
2.383.476
751
W-1-20-i
5.542.461
5.708.735
5.819.584
5.930.434
752
W-1-20-ii
6.904.198
7.111.324
7.249.408
7.387.492

NON KOMPLEK (BERAT)

RINGAN
SEDANG
BERAT

SERVIK RINGAN
SERVIK SEDANG
SERVIK BERAT
ENDOSKOP RINGAN
ENDOSKOP SEDANG
ENDOSKOP BERAT
- 894 No
Kode
INA-CBG
753
W-1-20-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
7.767.223
8.000.240
8.155.584
8.310.929
3.025.628
3.116.397
3.176.910
3.237.422
4.315.124
4.444.578
4.530.880
4.617.183
12.833.610
13.218.619
13.475.291
13.731.963
754
W-1-30-i
755
W-1-30-ii
756
W-1-30-iii
757
W-4-10-i
2.256.361
2.324.051
2.369.179
2.414.306
758
W-4-10-ii
3.049.724
3.141.216
3.202.210
3.263.205
759
W-4-10-iii
5.482.223
5.646.690
5.756.334
5.865.979
760
W-4-11-i
1.601.650
1.649.699
1.681.732
1.713.765
761
W-4-11-ii
2.687.872
2.768.509
2.822.266
2.876.023
762
W-4-11-iii
3.245.154
3.342.509
3.407.412
3.472.315
1.281.320
1.319.759
1.345.386
1.371.012
2.189.958
2.255.657
2.299.456
2.343.255
2.642.087
2.721.350
2.774.192
2.827.033

763
W-4-12-i
764
W-4-12-ii
765
W-4-12-iii
766
W-4-13-i
ABORTUS RINGAN
702.691
723.772
737.825
751.879
767
W-4-13-ii
ABORTUS SEDANG
960.990
989.820
1.009.039
1.028.259
768
W-4-13-iii
ABORTUS BERAT
1.281.320
1.319.759
1.345.386
1.371.012
769
W-4-14-i
960.990
989.820
1.009.039
1.028.259
770
W-4-14-ii
1.281.320
1.319.759
1.345.386
1.371.012
771
W-4-14-iii
1.555.251
1.601.909
1.633.014
1.664.119
772
W-4-15-i
960.990
989.820
1.009.039
1.028.259
773
W-4-15-ii
1.032.825
1.063.810
1.084.466
1.105.123
774
W-4-15-iii
1.306.707
1.345.908
1.372.042
1.398.176
775
W-4-16-i
1.081.439
1.113.882
1.135.511
1.157.140
776
W-4-16-ii
1.713.333
1.764.733
1.799.000
1.833.266
777
W-4-16-iii
2.183.606
2.249.114
2.292.786
2.336.458
778
W-4-17-i
960.990
989.820
1.009.039
1.028.259
779
W-4-17-ii
1.281.320
1.319.759
1.345.386
1.371.012
780
W-4-17-iii
2.424.002
2.496.722
2.545.202
2.593.682
781
Z-4-10-i
REHABILITASI RINGAN
2.220.728
2.287.350
2.331.765
2.376.179
782
Z-4-10-ii
REHABILITASI SEDANG
2.947.696
3.036.127
3.095.081
3.154.035
783
Z-4-10-iii
REHABILITASI BERAT
4.187.484
4.313.108
4.396.858
4.480.608
784
Z-4-11-i
2.581.426
2.658.869
2.710.497
2.762.126
785
Z-4-11-ii
3.107.466
3.200.690
3.262.840
3.324.989
786
Z-4-11-iii
4.858.096
5.003.839
5.101.001
5.198.163
- 895 No
Kode
INA-CBG
787
Z-4-12-i
788
Z-4-12-ii
789
Z-4-12-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
998.433
1.028.386
1.048.355
1.068.323
2.633.690
2.712.701
2.765.375
2.818.049
3.347.004
3.447.414
3.514.354
3.581.294
b. RawatJalan
No
Kode
INA-CBG
B-2-10-0
B-2-11-0
- 896 -
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
749.845
772.341
787.338
802.335
972.667
1.001.847
1.021.300
1.040.753
1.808.802
1.863.066
1.899.242
1.935.418
1.494.799
1.539.643
1.569.539
1.599.435
1.248.776
1.286.239
1.311.215
1.336.190
437.826
450.961
459.718
468.474

LAPAROSKOPI
PANKREAS
LAPAROSKOPI
EMPEDU
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
976.295
1.005.584
1.025.110
1.044.636
B-3-12-0

200.597
206.615
210.627
214.638
C-3-10-0
547.199
563.615
574.559
585.503
10
C-3-11-0

KANDUNG KEMIH
865.416
891.379
908.687
925.995
11
C-3-12-0
196.188
202.074
205.997
209.921
12
C-3-13-0
190.512
196.227
200.038
203.848
13
C-3-14-0
1.621.832
1.670.487
1.702.924
1.735.360
14
C-3-15-0
1.486.474
1.531.068
1.560.797
1.590.527
15
C-3-16-0
337.096
347.209
353.951
360.693
16
C-3-17-0

LEHER
223.620
230.328
234.801
239.273
17
C-3-18-0
99.143
102.118
104.101
106.083
18
C-3-19-0

MYELOMA ATAU TESTIS
140.209
144.415
147.219
150.024
19
C-3-20-0
2.792.265
2.876.033
2.931.878
2.987.724
20
C-3-21-0
160.003
164.804
168.004
171.204
21
C-3-22-0
702.500
723.575
737.625
751.675
22
C-3-23-0
113.790
117.203
119.479
121.755
23
D-2-10-0

TULANG
964.042
992.964
1.012.244
1.031.525
24
D-2-11-0
PROSEDUR LIMPA
1.207.146
1.243.360
1.267.503
1.291.646
25
D-2-21-0
1.012.453
1.042.827
1.063.076
1.083.325
26
D-2-22-0
222.203
228.869
233.313
237.757
27
D-3-10-0
160.947
165.776
168.995
172.213
28
D-3-11-0
417.865
430.401
438.758
447.116
29
E-2-10-0
247.874
255.311
260.268
265.226
30
E-2-21-0
179.700
185.092
188.686
192.280
31
E-2-22-0
179.700
185.092
188.686
192.280

OVARIUM
GASTROINTESTINAL
GINJAL ATAU PROSTAT

TYMUS
TYMUS
TULANG
PEMBENTUK DARAH
PARATIROID
THYROGLOSSAL
- 897 No
Kode
INA-CBG
32
E-3-10-0
33
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

ENDOKRIN
208.980
215.249
219.429
223.609
F-3-10-0
TERAPI SHOCK
291.520
300.266
306.096
311.927
34
F-5-10-0
357.207
367.923
375.067
382.211
35
F-5-11-0
TERAPI KELOMPOK
235.545
242.611
247.322
252.033
36
F-5-12-0
301.420
310.463
316.491
322.519
37
F-5-13-0
255.283
262.941
268.047
273.152
38
F-5-14-0
171.261
176.398
179.824
183.249
39
F-5-15-0
160.664
165.484
168.698
171.911
40
F-5-16-0
167.347
172.368
175.715
179.062
41
G-2-10-0
140.919
145.147
147.965
150.784
42
G-2-11-0
1.221.549
1.258.195
1.282.626
1.307.057
43
G-2-12-0

EKSTRAKRANIAL
1.770.325
1.823.434
1.858.841
1.894.247
44
G-2-13-0
434.300
447.329
456.015
464.701
45
G-2-21-0
792.090
815.853
831.695
847.537
46
G-2-22-0
718.889
740.456
754.834
769.211
47
G-2-31-0
1.186.230
1.221.817
1.245.541
1.269.266
48
G-2-32-0
608.060
626.302
638.463
650.625
49
G-3-10-0
241.343
248.583
253.410
258.237
50
G-3-11-0
321.423
331.065
337.494
343.922
51
G-3-12-0
526.657
542.456
552.989
563.522
52
G-3-13-0
526.717
542.518
553.052
563.587
53
H-2-21-0
691.237
711.974
725.799
739.624
54
H-2-22-0
179.700
185.092
188.686
192.280
55
H-2-23-0
179.700
185.092
188.686
192.280
56
H-2-31-0
1.144.977
1.179.326
1.202.226
1.225.126
57
H-2-32-0
119.165
122.740
125.124
127.507
58
H-2-33-0
179.700
185.092
188.686
192.280
59
H-2-34-0
513.665
529.075
539.348
549.621
60
H-2-35-0
169.264
174.342
177.727
181.113
61
H-2-36-0
913.648
941.058
959.331
977.604
62
H-2-37-0

972.619
1.001.797
1.021.250
1.040.702
63
H-3-10-0
338.400
348.552
355.320
362.088
64
H-3-11-0
177.961
183.300
186.859
190.418

AKUT
MENTAL
PROSEDUR KRANIOTOMI

MATA
MATA
MATA
MATA
MATA
- 898 No
Kode
INA-CBG
65
H-3-12-0
66
H-3-13-0
67
I-2-11-0
68
I-2-12-0
69
I-2-13-0
70
I-2-14-0
71
I-2-15-0
Deskripsi (INA-CBG)
MATA
TORASIK
ABDOMEN
PENGGANTIAN ALAT
DARAH VENA
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
185.800
191.374
195.090
198.806
180.401
185.813
189.421
193.029
2.080.408
2.142.820
2.184.428
2.226.036
1.462.754
1.506.636
1.535.891
1.565.147
1.859.072
1.914.844
1.952.026
1.989.207
3.290.162
3.388.866
3.454.670
3.520.473
197.864
203.800
207.757
211.714
2.078.153
2.140.498
2.182.061
2.223.624
685.107
705.661
719.363
733.065
72
I-2-16-0
73
I-2-17-0
74
I-2-21-0
1.604.039
1.652.160
1.684.241
1.716.322
75
I-2-22-0
1.510.484
1.555.798
1.586.008
1.616.217
76
I-2-23-0
309.116
318.389
324.572
330.754
77
I-2-31-0
2.404.099
2.476.222
2.524.304
2.572.386
78
I-2-32-0
3.143.712
3.238.024
3.300.898
3.363.772
79
I-2-41-0
2.107.898
2.171.135
2.213.293
2.255.451
80
I-2-42-0

LAIN
2.450.780
2.524.303
2.573.319
2.622.335
81
I-3-10-0
PROSEDUR RESUSITASI
311.105
320.438
326.660
332.882
82
I-3-11-0
164.200
169.126
172.410
175.694
83
I-3-12-0
954.271
982.899
1.001.984
1.021.070
84
I-3-13-0
313.419
322.822
329.090
335.359
85
I-3-14-0
200.891
206.918
210.936
214.954
177.961
183.300
186.859
190.418
1.101.820
1.134.875
1.156.911
1.178.948
177.613
182.942
186.494
190.046
895.060
921.912
939.813
957.714
1.160.973
1.195.802
1.219.021
1.242.241

PACU JANTUNG

KARDIOVASKULAR
PERNAFASAN
PENDEK
86
I-3-15-0
87
J-2-10-0
88
J-2-21-0
89
J-2-22-0
90
J-2-31-0
PROSEDUR
91
J-2-32-0
863.956
889.875
907.154
924.433
92
J-3-10-0
179.700
185.092
188.686
192.280
93
J-3-11-0

PADA DADA
507.802
523.036
533.192
543.348
94
J-3-12-0
196.188
202.074
205.997
209.921
95
J-3-13-0
288.740
297.402
303.177
308.952
96
J-3-14-0
306.529
315.725
321.855
327.986
- 899 No
Kode
INA-CBG
97
J-3-15-0
98
J-3-16-0
99
J-3-17-0
100
K-2-10-0
101
K-2-11-0
102
K-2-12-0

103
K-2-13-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
268.801
276.865
282.241
287.617
306.529
315.725
321.855
327.986
179.700
185.092
188.686
192.280
517.240
532.757
543.102
553.446
1.104.517
1.137.653
1.159.743
1.181.834
847.860
873.295
890.253
907.210
1.379.937
1.421.336
1.448.934
1.476.533
179.700
185.092
188.686
192.280
179.700
185.092
188.686
192.280
2.309.579
2.378.867
2.425.058
2.471.250
776.594
799.892
815.424
830.956
179.700
185.092
188.686
192.280

PERNAFASAN
KECIL

FEMORALIS
USUS BESAR
ATAS
ATAS
104
K-2-14-0
105
K-2-21-0
106
K-2-22-0
107
K-2-31-0
108
K-2-32-0
109
K-2-41-0
855.435
881.098
898.206
915.315
110
K-2-42-0

244.408
251.740
256.629
261.517
111
K-2-51-0
566.863
583.869
595.206
606.543
112
K-2-52-0
309.116
318.389
324.572
330.754
113
K-2-53-0
179.700
185.092
188.686
192.280
114
K-3-10-0

GASTROINTESTINAL
341.958
352.217
359.056
365.895
115
K-3-11-0
205.584
211.751
215.863
219.974
116
K-3-12-0
208.488
214.742
218.912
223.082
117
K-3-13-0
179.700
185.092
188.686
192.280
481.601
496.049
505.681
515.313
232.572
239.549
244.201
248.852
308.173
317.418
323.581
329.745
1.059.509
1.091.294
1.112.484
1.133.674
679.138
699.512
713.095
726.677
306.529
315.725
321.855
327.986
309.116
318.389
324.572
330.754

GASTROINTESTINAL
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
118
K-3-14-0
119
K-3-15-0
120
K-3-16-0
121
L-2-21-0
122
L-2-22-0
123
L-2-31-0
124
L-2-32-0
125
L-2-41-0
925.611
953.379
971.892
990.404
126
L-2-42-0

207.600
213.828
217.980
222.132
127
L-2-51-0
1.385.785
1.427.358
1.455.074
1.482.790
L-2-52-0

1.060.171
1.091.976
1.113.180
1.134.383
128
- 900 No
Kode
INA-CBG
129
L-2-53-0
130
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

179.700
185.092
188.686
192.280
L-3-10-0
244.408
251.740
256.629
261.517
131
L-3-11-0
237.337
244.457
249.204
253.951
132
L-3-12-0
180.755
186.178
189.793
193.408
133
M-2-10-0
1.417.759
1.460.291
1.488.647
1.517.002
134
M-2-21-0
1.269.701
1.307.792
1.333.186
1.358.580
135
M-2-22-0
309.116
318.389
324.572
330.754
136
M-2-31-0
PROSEDUR BUNION
771.216
794.352
809.777
825.201
137
M-2-32-0
244.408
251.740
256.629
261.517
138
M-2-41-0

TULANG
244.408
251.740
256.629
261.517
139
M-2-42-0
84.230
86.757
88.441
90.126
140
M-2-51-0
179.700
185.092
188.686
192.280
141
M-2-52-0
179.700
185.092
188.686
192.280
142
M-2-61-0
PROSEDUR ARTROSKOPI
880.806
907.230
924.847
942.463
143
M-2-62-0
179.700
185.092
188.686
192.280
885.571
912.138
929.850
947.561
1.207.736
1.243.968
1.268.123
1.292.277
179.700
185.092
188.686
192.280
891.627
918.375
936.208
954.040
860.458
886.271
903.481
920.690

DAN WAJAH
PAHA
PAHA

TULANG
WAJAH
WAJAH
BAWAH
BAWAH
144
M-2-63-0
145
M-2-64-0
146
M-2-65-0
147
M-2-71-0
148
M-2-72-0
149
M-2-81-0
1.283.126
1.321.619
1.347.282
1.372.944
150
M-2-82-0
932.108
960.072
978.714
997.356
151
M-2-83-0
179.700
185.092
188.686
192.280
152
M-2-84-0
179.700
185.092
188.686
192.280
153
M-3-10-0
512.900
528.287
538.545
548.803
154
M-3-11-0
284.372
292.903
298.590
304.278
155
M-3-12-0
643.085
662.377
675.239
688.101
156
M-3-13-0
209.663
215.953
220.146
224.339
157
M-3-14-0

TERTUTUP
358.350
369.100
376.267
383.434
158
M-3-15-0
157.875
162.611
165.769
168.926
159
M-3-16-0

179.700
185.092
188.686
192.280
160
M-3-17-0
196.188
202.074
205.997
209.921
161
N-2-11-0
2.374.020
2.445.241
2.492.721
2.540.201

PERGELANGAN TANGAN
PERGELANGAN TANGAN
MUSKULOSKELETAL
SKELETAL
- 901 No
Kode
INA-CBG
162
N-2-12-0
163
N-2-21-0
164
N-2-22-0
165
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.373.347
1.414.548
1.442.014
1.469.481
1.366.108
1.407.091
1.434.413
1.461.736
309.116
318.389
324.572
330.754
N-2-23-0
309.116
318.389
324.572
330.754
166
N-2-24-0
998.959
1.028.928
1.048.907
1.068.886
167
N-2-31-0
840.961
866.190
883.010
899.829
168
N-2-32-0
309.116
318.389
324.572
330.754
169
N-2-41-0
309.116
318.389
324.572
330.754
170
N-2-42-0
522.774
538.457
548.913
559.368
171
N-3-10-0
309.116
318.389
324.572
330.754
172
N-3-11-0
358.155
368.900
376.063
383.226
173
N-3-12-0
276.762
285.065
290.600
296.135
174
N-3-13-0
309.116
318.389
324.572
330.754
175
N-3-14-0
265.977
273.957
279.276
284.596
176
N-3-15-0
682.033
702.494
716.135
729.775
177
O-7-10-0
113.870
117.286
119.564
121.841
178
O-7-11-0
627.113
645.926
658.469
671.011
179
O-7-12-0
228.353
235.204
239.771
244.338
180
O-7-13-0
126.909
130.716
133.254
135.792
181
P-9-10-0
169.264
174.342
177.727
181.113
182
P-9-11-0
169.264
174.342
177.727
181.113
183
P-9-12-0
169.264
174.342
177.727
181.113
184
P-9-13-0
169.264
174.342
177.727
181.113
185
P-9-14-0
169.264
174.342
177.727
181.113
186
P-9-15-0
107.893
111.129
113.287
115.445
187
P-9-16-0
169.264
174.342
177.727
181.113
188
P-9-17-0
168.536
173.592
176.963
180.334
189
Q-5-10-0
220.605
227.223
231.635
236.048
190
Q-5-11-0
165.338
170.298
173.604
176.911
191
Q-5-12-0
GIGI
145.724
150.096
153.010
155.925
192
Q-5-13-0
MEDICAL CHECK-UP
110.744
114.066
116.281
118.496
193
Q-5-14-0
121.855
125.510
127.947
130.384


DAN URETHRA
DAN URETHRA
TRANSURETHRA
TRANSURETHRA
SALURAN KEMIH
KEMIH
KEMIH
PROSEDUR DIALISIS
CAESAR
VAGINAL/JALAN LAHIR

ASPIRASI
- 902 No
Kode
INA-CBG
194
Q-5-15-0
195
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
83.799
86.313
87.989
89.665
Q-5-16-0
VAKSINASI
94.713
97.554
99.448
101.342
196
Q-5-17-0
PASANG INFUS
81.924
84.382
86.020
87.659
197
Q-5-18-0
154.206
158.833
161.917
165.001
198
Q-5-19-0
172.394
177.565
181.013
184.461
199
Q-5-20-0
ABORSI MENGANCAM
115.550
119.016
121.327
123.638
200
Q-5-21-0
ABORSI
113.976
117.395
119.675
121.954
201
Q-5-22-0
121.855
125.510
127.947
130.384
202
Q-5-23-0
149.182
153.658
156.641
159.625
203
Q-5-24-0
101.889
104.946
106.984
109.022
204
Q-5-25-0
158.894
163.661
166.839
170.017
205
Q-5-26-0
BRONKIAL AKUT
224.904
231.651
236.149
240.647
206
Q-5-27-0
160.053
164.854
168.055
171.256
207
Q-5-28-0
129.879
133.775
136.372
138.970
208
Q-5-29-0

JANTUNG LAIN-LAIN
367.708
378.739
386.093
393.447
209
Q-5-30-0
426.133
438.917
447.440
455.963
210
Q-5-31-0
FRAKTUR
152.027
156.588
159.629
162.669
211
Q-5-32-0
SALURAN KEMIH AKUT
176.082
181.364
184.886
188.408
212
Q-5-33-0
HEMATOLOGI AKUT
184.357
189.888
193.575
197.262
213
Q-5-34-0
INFEKSI VIRUS HIV
261.892
269.749
274.987
280.225
214
Q-5-35-0
INFEKSI AKUT
296.979
305.888
311.828
317.767
215
Q-5-36-0
345.851
356.226
363.143
370.060
216
Q-5-37-0

SHOCK
176.402
181.694
185.222
188.750
217
Q-5-38-0
PARU AKUT
235.237
242.294
246.999
251.704
218
Q-5-39-0
150.534
155.051
158.061
161.072
219
Q-5-40-0
147.698
152.129
155.083
158.037
220
Q-5-41-0
204.468
210.602
214.691
218.780
221
Q-5-42-0
160.311
165.120
168.326
171.532
222
Q-5-43-0
230.857
237.782
242.400
247.017
223
Q-5-44-0
188.411
194.063
197.832
201.600
224
T-2-10-0

TERAPI DETOKSIKASI
1.233.880
1.270.897
1.295.574
1.320.252
225
U-2-10-0
1.304.259
1.343.387
1.369.472
1.395.557
226
U-2-11-0

LEHER
1.550.257
1.596.765
1.627.770
1.658.775
227
U-2-12-0
170.569
175.686
179.097
182.509
- 903 No
Kode
INA-CBG
228
U-2-13-0
229
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
223.620
230.328
234.801
239.273
U-2-14-0
415.384
427.846
436.153
444.461
230
U-2-15-0
236.012
243.093
247.813
252.533
231
U-2-21-0
274.917
283.165
288.663
294.162
232
U-2-22-0
531.163
547.097
557.721
568.344
233
U-2-23-0
695.995
716.874
730.794
744.714
234
U-2-24-0
586.572
604.169
615.901
627.632
235
U-2-25-0
223.620
230.328
234.801
239.273
236
U-2-31-0
179.700
185.092
188.686
192.280
237
U-2-32-0
223.620
230.328
234.801
239.273
238
U-3-10-0
213.792
220.206
224.482
228.758
239
U-3-11-0
226.981
233.790
238.330
242.869
240
U-3-12-0
100.371
103.382
105.389
107.397
241
U-3-13-0
220.622
227.241
231.654
236.066
242
U-3-14-0
202.707
208.788
212.842
216.896
243
U-3-15-0
176.778
182.082
185.617
189.153
244
U-3-16-0
PROSEDUR PADA GIGI
199.374
205.355
209.342
213.330
245
V-2-10-0

PROSTAT
1.945.121
2.003.474
2.042.377
2.081.279
246
V-2-11-0
219.360
225.941
230.328
234.715
700.009
721.010
735.010
749.010
309.116
318.389
324.572
330.754
309.116
318.389
324.572
330.754

(RHINOPLASTY)

RONGGA HIDUNG
TENGGOROKAN
PROSEDUR PADA PENIS

SKROTUM
SKROTUM
TRANSURETHRAL
247
V-2-12-0
248
V-2-13-0
249
V-2-14-0
250
V-2-15-0
SIRKUMSISI/SUNAT
169.264
174.342
177.727
181.113
251
V-3-10-0
353.012
363.602
370.662
377.723
252
V-3-11-0
746.803
769.207
784.143
799.079
253
V-3-12-0
431.149
444.083
452.706
461.329
254
W-2-10-0
157.875
162.611
165.769
168.926
255
W-2-11-0
403.469
415.573
423.643
431.712
256
W-2-12-0
746.803
769.207
784.143
799.079
257
W-2-13-0
119.774
123.367
125.763
128.158
258
W-2-21-0
1.501.273
1.546.311
1.576.336
1.606.362
259
W-2-22-0
157.875
162.611
165.769
168.926

PROSEDUR ABORSI
RAHIM & LEHER RAHIM
TERHALANG/TERGANGGU
TERHALANG/TERGANGGU
PANGGUL TERBUKA
PANGGUL TERBUKA
- 904 No
Kode
INA-CBG
260
W-2-23-0
Deskripsi (INA-CBG)
JALAN LAHIR
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
526.836
542.641
553.178
563.715
1.729.443
1.781.326
1.815.915
1.850.504
1.212.937
1.249.325
1.273.584
1.297.842
261
W-2-31-0
262
W-2-32-0
263
W-2-33-0
515.514
530.980
541.290
551.600
264
W-2-34-0
175.335
180.595
184.102
187.609
265
W-3-10-0
426.133
438.917
447.440
455.962
266
W-3-11-0
340.638
350.858
357.670
364.483
267
W-3-12-0
157.875
162.611
165.769
168.926
268
Z-3-10-0
1.787.354
1.840.975
1.876.722
1.912.469
269
Z-3-11-0

EMPEDU
1.366.108
1.407.091
1.434.413
1.461.736
270
Z-3-12-0
228.107
234.950
239.512
244.074
271
Z-3-13-0

LAIN-LAIN
1.391.971
1.433.731
1.461.570
1.489.409
272
Z-3-14-0
DIAGNOSTIK TIDUR
275.236
283.493
288.998
294.502
273
Z-3-15-0
179.700
185.092
188.686
192.280
274
Z-3-16-0

(MRI)
576.784
594.088
605.623
617.159
275
Z-3-17-0
PENGOBATAN NUKLIR
242.146
249.411
254.254
259.097
276
Z-3-18-0
CT-SCAN KEPALA
233.303
240.302
244.969
249.635
277
Z-3-19-0
CT SCAN LAIN-LAIN
242.823
250.108
254.965
259.821
278
Z-3-20-0
165.150
170.105
173.408
176.711
279
Z-3-21-0
157.875
162.611
165.769
168.926
280
Z-3-22-0
177.990
183.329
186.889
190.449
281
Z-3-23-0
185.392
190.953
194.661
198.369
282
Z-3-24-0
364.258
375.186
382.471
389.756
283
Z-3-25-0
162.240
167.107
170.352
173.597
284
Z-3-26-0
183.363
188.864
192.531
196.199
285
Z-3-27-0
PERAWATAN LUKA
175.062
180.314
183.815
187.316
286
Z-3-28-0
IMAGING PAYUDARA
179.700
185.092
188.686
192.280
287
Z-3-29-0
IMAGING LAIN-LAIN
517.929
533.467
543.826
554.184
288
Z-3-30-0
FOTOTERAPI
87.407
90.029
91.778
93.526
- 905 2. RUMAH SAKIT KUSTAKELAS D

a. RawatInap
No
Kode
INA-CBG
A-4-10-i
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
SEPTIKEMIA RINGAN
1.817.415
1.871.937
1.908.286
1.944.634
A-4-10-ii
SEPTIKEMIA SEDANG
2.080.451
2.142.865
2.184.474
2.226.083
A-4-10-iii
SEPTIKEMIA BERAT
3.261.755
3.359.608
3.424.843
3.490.078
A-4-11-i
3.266.319
3.364.308
3.429.634
3.494.961
A-4-11-ii

SEDANG
5.046.085
5.197.467
5.298.389
5.399.311
A-4-11-iii
8.254.292
8.501.921
8.667.007
8.832.093
A-4-12-i
DEMAM RINGAN
1.281.320
1.319.759
1.345.386
1.371.012
A-4-12-ii
DEMAM SEDANG
1.837.776
1.892.909
1.929.665
1.966.420
A-4-12-iii
DEMAM BERAT
2.103.200
2.166.296
2.208.360
2.250.424
10
A-4-13-i
1.601.650
1.649.699
1.681.732
1.713.765
11
A-4-13-ii
1.921.980
1.979.639
2.018.079
2.056.518
12
A-4-13-iii
2.335.939
2.406.017
2.452.736
2.499.455
13
A-4-14-i
101.483
104.527
106.557
108.587
14
A-4-14-ii
130.590
134.508
137.120
139.731
15
A-4-14-iii
149.212
153.689
156.673
159.657
16
A-4-15-i
INFEKSI HIV RINGAN
1.921.980
1.979.639
2.018.079
2.056.518
17
A-4-15-ii
INFEKSI HIV SEDANG
2.882.970
2.969.459
3.027.118
3.084.778
18
A-4-15-iii
INFEKSI HIV BERAT
4.009.532
4.129.817
4.210.008
4.290.199
19
B-1-01-i
21.308.142
21.947.386
22.373.549
22.799.712
20
B-1-01-ii
23.508.577
24.213.835
24.684.006
25.154.178
21
B-1-01-iii
41.238.882
42.476.049
43.300.826
44.125.604
22
B-1-10-i
2.762.528
2.845.404
2.900.655
2.955.905
23
B-1-10-ii
7.040.253
7.251.460
7.392.265
7.533.070
24
B-1-10-iii
12.254.294
12.621.923
12.867.009
13.112.095
25
B-1-11-i
1.888.549
1.945.205
1.982.976
2.020.747
26
B-1-11-ii
4.740.436
4.882.649
4.977.458
5.072.267
27
B-1-11-iii
5.943.331
6.121.630
6.240.497
6.359.364
28
B-1-12-i
4.028.343
4.149.193
4.229.760
4.310.327
29
B-1-12-ii
8.633.725
8.892.736
9.065.411
9.238.085
30
B-1-12-iii
10.507.568
10.822.795
11.032.947
11.243.098

LAIN-LAIN RINGAN
LAIN-LAIN SEDANG
LAIN-LAIN BERAT

(RINGAN)
(SEDANG)
(BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT
- 906 No
Kode
INA-CBG
31
B-1-13-i
32
B-1-13-ii
33
B-1-13-iii
34
B-1-14-i
35
B-1-14-ii
36
B-1-14-iii
37
B-4-10-i
38
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.639.684
2.718.874
2.771.668
2.824.461
4.299.661
4.428.651
4.514.645
4.600.638
6.338.908
6.529.075
6.655.853
6.782.631
3.584.505
3.692.040
3.763.730
3.835.420
3.986.692
4.106.293
4.186.027
4.265.761
6.236.706
6.423.808
6.548.542
6.673.276
1.002.468
1.032.542
1.052.591
1.072.641
B-4-10-ii
1.601.650
1.649.699
1.681.732
1.713.765
39
B-4-10-iii
2.448.732
2.522.194
2.571.169
2.620.144
40
B-4-11-i
2.421.352
2.493.993
2.542.420
2.590.847
41
B-4-11-ii
3.681.060
3.791.491
3.865.113
3.938.734
42
B-4-11-iii
3.964.629
4.083.568
4.162.861
4.242.153
43
B-4-12-i
2.124.570
2.188.308
2.230.799
2.273.290
44
B-4-12-ii
3.012.118
3.102.482
3.162.724
3.222.966
45
B-4-12-iii
5.854.322
6.029.952
6.147.038
6.264.125
46
B-4-13-i
1.921.980
1.979.639
2.018.079
2.056.518
47
B-4-13-ii
2.999.355
3.089.335
3.149.323
3.209.310
48
B-4-13-iii
4.552.384
4.688.956
4.780.003
4.871.051
49
B-4-14-i
1.921.980
1.979.639
2.018.079
2.056.518
50
B-4-14-ii
2.242.310
2.309.579
2.354.425
2.399.271
51
B-4-14-iii
2.991.467
3.081.211
3.141.040
3.200.869
52
C-4-10-i
1.871.620
1.927.769
1.965.201
2.002.634
53
C-4-10-ii
3.636.362
3.745.453
3.818.180
3.890.907
54
C-4-10-iii
LEUKEMIA AKUT BERAT
6.086.269
6.268.857
6.390.583
6.512.308
55
C-4-11-i
1.921.980
1.979.639
2.018.079
2.056.518
56
C-4-11-ii
2.562.640
2.639.519
2.690.772
2.742.024
57
C-4-11-iii
4.356.787
4.487.491
4.574.627
4.661.763
58
C-4-12-i
RADIOTERAPI RINGAN
1.281.320
1.319.759
1.345.386
1.371.012
59
C-4-12-ii
RADIOTERAPI SEDANG
3.527.860
3.633.696
3.704.253
3.774.811
60
C-4-12-iii
RADIOTERAPI BERAT
7.162.263
7.377.131
7.520.377
7.663.622
61
C-4-13-i
KEMOTERAPI RINGAN
1.281.320
1.319.759
1.345.386
1.371.012
62
C-4-13-ii
KEMOTERAPI SEDANG
2.562.640
2.639.519
2.690.772
2.742.024
63
C-4-13-iii
KEMOTERAPI BERAT
3.353.024
3.453.615
3.520.676
3.587.736

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT

PANCREAS RINGAN
PANCREAS SEDANG
PANCREAS BERAT
(RINGAN)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT
- 907 No
Kode
INA-CBG
64
C-4-14-i
65
C-4-14-ii
66
C-4-14-iii
67
D-1-10-i
68
D-1-10-ii
69
D-1-10-iii
70
D-1-11-i
71
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.661.529
1.711.375
1.744.605
1.777.836
2.427.932
2.500.770
2.549.329
2.597.888
3.701.313
3.812.352
3.886.378
3.960.405
13.634.763
14.043.806
14.316.501
14.589.196
20.766.789
21.389.793
21.805.129
22.220.465
28.144.674
28.989.014
29.551.908
30.114.801
2.802.508
2.886.584
2.942.634
2.998.684
D-1-11-ii
7.309.456
7.528.740
7.674.929
7.821.118
72
D-1-11-iii
10.356.298
10.666.987
10.874.113
11.081.239
73
D-1-20-i
3.452.099
3.555.662
3.624.704
3.693.746
74
D-1-20-ii
7.767.223
8.000.240
8.155.584
8.310.929
75
D-1-20-iii
14.040.542
14.461.758
14.742.569
15.023.380
76
D-4-10-i
1.230.786
1.267.710
1.292.326
1.316.941
77
D-4-10-ii
2.485.189
2.559.745
2.609.449
2.659.153
78
D-4-10-iii
3.203.300
3.299.399
3.363.465
3.427.531
79
D-4-11-i
2.802.887
2.886.974
2.943.031
2.999.089
80
D-4-11-ii
5.009.514
5.159.799
5.259.989
5.360.179
81
D-4-11-iii
6.858.324
7.064.074
7.201.240
7.338.407
82
D-4-12-i
1.642.987
1.692.277
1.725.136
1.757.996
83
D-4-12-ii
2.278.985
2.347.354
2.392.934
2.438.513
84
D-4-12-iii
3.499.382
3.604.364
3.674.351
3.744.339
85
D-4-13-i
1.281.320
1.319.759
1.345.386
1.371.012
86
D-4-13-ii
1.921.980
1.979.639
2.018.079
2.056.518
87
D-4-13-iii
2.242.310
2.309.579
2.354.425
2.399.271
88
D-4-14-i
1.543.834
1.590.149
1.621.026
1.651.903
89
D-4-14-ii
3.604.475
3.712.609
3.784.699
3.856.788
90
D-4-14-iii
4.299.640
4.428.629
4.514.622
4.600.615
91
E-1-01-i
3.071.459
3.163.603
3.225.032
3.286.461
92
E-1-01-ii
4.023.319
4.144.019
4.224.485
4.304.952
93
E-1-01-iii
9.118.946
9.392.515
9.574.894
9.757.272
94
E-1-10-i
3.129.652
3.223.542
3.286.135
3.348.728
95
E-1-10-ii
3.798.663
3.912.623
3.988.597
4.064.570
96
E-1-10-iii
8.006.464
8.246.658
8.406.787
8.566.917

RINGAN
SEDANG
BERAT
TULANG RINGAN
TULANG SEDANG
TULANG BERAT


RINGAN
SEDANG
BERAT
- 908 No
Kode
INA-CBG
97
E-1-20-i
98
E-1-20-ii
99
E-1-20-iii
100
E-4-10-i
101
E-4-10-ii
102
E-4-10-iii
103
E-4-11-i
104
E-4-11-ii
105
E-4-11-iii
106
E-4-12-i
107
108
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.624.202
3.732.928
3.805.412
3.877.896
4.854.033
4.999.654
5.096.735
5.193.816
10.755.166
11.077.821
11.292.924
11.508.028
1.601.650
1.649.699
1.681.732
1.713.765
2.277.883
2.346.220
2.391.777
2.437.335
4.354.129
4.484.753
4.571.835
4.658.918
1.366.542
1.407.539
1.434.869
1.462.200
2.585.263
2.662.821
2.714.526
2.766.232
4.263.218
4.391.115
4.476.379
4.561.644
1.632.827
1.681.812
1.714.468
1.747.125
E-4-12-ii
2.836.528
2.921.624
2.978.355
3.035.085
E-4-12-iii
4.631.833
4.770.788
4.863.425
4.956.062
1.722.313
1.773.982
1.808.429
1.842.875
2.957.223
3.045.940
3.105.085
3.164.229
5.116.743
5.270.246
5.372.580
5.474.915

RINGAN
SEDANG
BERAT

RINGAN
SEDANG
BERAT
109
E-4-13-i
110
E-4-13-ii
111
E-4-13-iii
112
F-4-10-i
SCHIZOFRENIA RINGAN
2.105.853
2.169.029
2.211.146
2.253.263
113
F-4-10-ii
SCHIZOFRENIA SEDANG
2.338.618
2.408.776
2.455.549
2.502.321
114
F-4-10-iii
SCHIZOFRENIA BERAT
3.462.375
3.566.247
3.635.494
3.704.742
115
F-4-11-i
1.941.087
1.999.319
2.038.141
2.076.963
116
F-4-11-ii
2.261.550
2.329.397
2.374.628
2.419.859
117
F-4-11-iii
DEPRESI MAYOR BERAT
2.900.134
2.987.138
3.045.141
3.103.143

IMPULSE RINGAN
IMPULSE SEDANG
IMPULSE BERAT
960.990
989.820
1.009.039
1.028.259
1.372.157
1.413.322
1.440.765
1.468.208
2.976.665
3.065.965
3.125.498
3.185.031
118
F-4-12-i
119
F-4-12-ii
120
F-4-12-iii
121
F-4-13-i
1.568.693
1.615.754
1.647.128
1.678.501
122
F-4-13-ii
2.077.353
2.139.673
2.181.220
2.222.767
123
F-4-13-iii
2.678.481
2.758.835
2.812.405
2.865.975
124
F-4-14-i
DEPRESI RINGAN
1.098.085
1.131.028
1.152.989
1.174.951
125
F-4-14-ii
DEPRESI SEDANG
1.408.517
1.450.772
1.478.943
1.507.113
126
F-4-14-iii
DEPRESI BERAT
1.895.222
1.952.079
1.989.983
2.027.888
127
F-4-15-i
1.305.561
1.344.727
1.370.839
1.396.950
128
F-4-15-ii
1.921.980
1.979.639
2.018.079
2.056.518
129
F-4-15-iii
2.531.365
2.607.306
2.657.933
2.708.561
- 909 No
Kode
INA-CBG
130
F-4-16-i
131
F-4-16-ii
132
F-4-16-iii
133
F-4-17-i
134
F-4-17-ii
135
F-4-17-iii
136
F-4-18-i
137
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.811.922
2.896.280
2.952.518
3.008.757
3.268.789
3.366.853
3.432.229
3.497.604
4.363.288
4.494.187
4.581.452
4.668.718
649.240
668.717
681.702
694.686
1.902.859
1.959.945
1.998.002
2.036.059
2.030.211
2.091.117
2.131.721
2.172.326
2.437.279
2.510.398
2.559.143
2.607.889
F-4-18-ii
2.681.696
2.762.147
2.815.781
2.869.414
138
F-4-18-iii
4.134.068
4.258.090
4.340.771
4.423.453
139
F-4-19-i
1.869.163
1.925.238
1.962.622
2.000.005
140
F-4-19-ii
2.393.512
2.465.317
2.513.187
2.561.058
141
F-4-19-iii
2.979.954
3.069.353
3.128.952
3.188.551
142
G-1-01-i
5.942.469
6.120.743
6.239.593
6.358.442
143
G-1-01-ii
10.058.345
10.360.095
10.561.262
10.762.429
144
G-1-01-iii
19.471.833
20.055.988
20.445.424
20.834.861
145
G-1-10-i
2.965.592
3.054.560
3.113.871
3.173.183
146
G-1-10-ii
4.186.678
4.312.279
4.396.012
4.479.746
147
G-1-10-iii
4.962.108
5.110.971
5.210.214
5.309.456
148
G-1-11-i
3.420.899
3.523.526
3.591.944
3.660.362
149
G-1-11-ii
7.025.073
7.235.825
7.376.327
7.516.828
150
G-1-11-iii
14.709.865
15.151.161
15.445.358
15.739.555
151
G-1-12-i
2.660.451
2.740.265
2.793.474
2.846.683
152
G-1-12-ii
6.090.838
6.273.563
6.395.380
6.517.197
153
G-1-12-iii
10.742.903
11.065.190
11.280.048
11.494.906
154
G-1-13-i
701.644
722.693
736.726
750.759
155
G-1-13-ii
1.884.539
1.941.075
1.978.765
2.016.456
156
G-1-13-iii
4.252.313
4.379.882
4.464.928
4.549.975
3.352.395
3.452.967
3.520.015
3.587.063
4.529.195
4.665.071
4.755.655
4.846.239
11.089.202
11.421.878
11.643.662
11.865.446

RINGAN
SEDANG
BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

RINGAN
SEDANG
BERAT
157
G-1-20-i
158
G-1-20-ii
159
G-1-20-iii
160
G-1-30-i
4.275.678
4.403.948
4.489.462
4.574.975
161
G-1-30-ii
11.159.929
11.494.727
11.717.926
11.941.125
162
G-1-30-iii
14.366.278
14.797.266
15.084.592
15.371.917
- 910 No
Kode
INA-CBG
163
G-4-10-i
164
G-4-10-ii
165
G-4-10-iii
166
G-4-11-i
167
G-4-11-ii
168
G-4-11-iii
169
G-4-12-i
170
G-4-12-ii
171
G-4-12-iii
172
G-4-13-i
173
G-4-13-ii
174
G-4-13-iii
175
G-4-14-i
176
G-4-14-ii
177
G-4-14-iii
178
G-4-15-i
179
G-4-15-ii
180
G-4-15-iii
181
G-4-16-i
182
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.921.980
1.979.639
2.018.079
2.056.518
2.242.310
2.309.579
2.354.425
2.399.271
3.425.627
3.528.396
3.596.909
3.665.421
3.171.129
3.266.263
3.329.685
3.393.108
3.678.509
3.788.865
3.862.435
3.936.005
5.390.919
5.552.647
5.660.465
5.768.283
2.371.725
2.442.877
2.490.312
2.537.746
2.988.374
3.078.025
3.137.793
3.197.560
4.340.257
4.470.465
4.557.270
4.644.075
1.319.612
1.359.200
1.385.593
1.411.985
2.242.310
2.309.579
2.354.425
2.399.271
2.650.728
2.730.250
2.783.265
2.836.279
2.413.374
2.485.775
2.534.042
2.582.310
3.970.814
4.089.939
4.169.355
4.248.771
4.971.550
5.120.696
5.220.127
5.319.558
2.470.158
2.544.263
2.593.666
2.643.069
2.984.816
3.074.360
3.134.057
3.193.753
3.688.418
3.799.071
3.872.839
3.946.607
1.601.650
1.649.699
1.681.732
1.713.765
G-4-16-ii
2.395.282
2.467.140
2.515.046
2.562.952
183
G-4-16-iii
4.347.008
4.477.419
4.564.359
4.651.299
184
G-4-17-i
2.288.904
2.357.571
2.403.349
2.449.127
185
G-4-17-ii
2.840.631
2.925.850
2.982.662
3.039.475
186
G-4-17-iii
4.760.920
4.903.748
4.998.966
5.094.185
187
G-4-18-i
1.921.980
1.979.639
2.018.079
2.056.518
188
G-4-18-ii
2.755.786
2.838.460
2.893.576
2.948.691
189
G-4-18-iii
2.919.475
3.007.059
3.065.449
3.123.838
190
G-4-19-i
1.601.650
1.649.699
1.681.732
1.713.765
191
G-4-19-ii
3.245.959
3.343.337
3.408.257
3.473.176

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
DEGENERATIF RINGAN
DEGENERATIF SEDANG
DEGENERATIF BERAT
RINGAN
SEDANG
BERAT
TRAUMATIK RINGAN
TRAUMATIK SEDANG
TRAUMATIK BERAT
DENGAN INFARK BERAT
TANPA INFARK RINGAN
TANPA INFARK SEDANG
TANPA INFARK BERAT

PERIFER RINGAN
PERIFER SEDANG
PERIFER BERAT
PERSARAFAN RINGAN
PERSARAFAN SEDANG
PERSARAFAN BERAT
RINGAN
SEDANG
- 911 No
Kode
INA-CBG
192
G-4-19-iii
193
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

4.841.940
4.987.198
5.084.037
5.180.876
G-4-20-i
1.121.155
1.154.790
1.177.213
1.199.636
194
G-4-20-ii
1.592.041
1.639.802
1.671.643
1.703.484
195
G-4-20-iii
2.714.803
2.796.247
2.850.543
2.904.839
196
G-4-21-i
1.299.162
1.338.137
1.364.120
1.390.103
197
G-4-21-ii
2.690.695
2.771.415
2.825.229
2.879.043
198
G-4-21-iii
3.169.956
3.265.054
3.328.453
3.391.852
199
G-4-22-i
1.281.320
1.319.759
1.345.386
1.371.012
200
G-4-22-ii
1.601.650
1.649.699
1.681.732
1.713.765
201
G-4-22-iii
1.837.511
1.892.636
1.929.387
1.966.137
202
G-4-23-i
1.281.320
1.319.759
1.345.386
1.371.012
203
G-4-23-ii
1.601.650
1.649.699
1.681.732
1.713.765
204
G-4-23-iii
2.289.445
2.358.128
2.403.917
2.449.706
205
G-4-24-i
1.281.320
1.319.759
1.345.386
1.371.012
206
G-4-24-ii
1.601.650
1.649.699
1.681.732
1.713.765
207
G-4-24-iii
TRAUMA KEPALA BERAT
3.365.694
3.466.665
3.533.978
3.601.292
208
G-4-25-i
GEGAR OTAK RINGAN
1.217.504
1.254.029
1.278.379
1.302.729
209
G-4-25-ii
GEGAR OTAK SEDANG
1.532.864
1.578.850
1.609.508
1.640.165
210
G-4-25-iii
GEGAR OTAK BERAT
1.999.964
2.059.963
2.099.962
2.139.962
211
G-4-26-i
1.921.980
1.979.639
2.018.079
2.056.518
212
G-4-26-ii
2.242.310
2.309.579
2.354.425
2.399.271
213
G-4-26-iii
4.280.256
4.408.663
4.494.268
4.579.873
214
H-1-20-i
1.841.758
1.897.011
1.933.846
1.970.682
215
H-1-20-ii
3.358.655
3.459.415
3.526.588
3.593.761
216
H-1-20-iii
4.567.561
4.704.588
4.795.939
4.887.290
1.803.257
1.857.355
1.893.420
1.929.485
2.055.713
2.117.384
2.158.499
2.199.613

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)

RINGAN
SEDANG
217
H-1-30-i
218
H-1-30-ii
219
H-1-30-iii
3.429.883
3.532.779
3.601.377
3.669.974
220
H-4-10-i
1.921.980
1.979.639
2.018.079
2.056.518
221
H-4-10-ii
3.203.300
3.299.399
3.363.465
3.427.531
222
H-4-10-iii
5.222.324
5.378.994
5.483.441
5.587.887
223
H-4-11-i
1.308.657
1.347.917
1.374.090
1.400.263
224
H-4-11-ii
1.462.229
1.506.096
1.535.341
1.564.585
225
H-4-11-iii
2.090.851
2.153.577
2.195.394
2.237.211
- 912 No
Kode
INA-CBG
226
H-4-12-i
227
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.815.709
1.870.181
1.906.495
1.942.809
H-4-12-ii
2.459.497
2.533.282
2.582.472
2.631.662
228
H-4-12-iii
4.103.503
4.226.608
4.308.678
4.390.748
229
I-1-01-i
27.642.940
28.472.229
29.025.087
29.577.946
230
I-1-01-ii
28.251.229
29.098.766
29.663.791
30.228.815
231
I-1-01-iii
44.594.023
45.931.844
46.823.725
47.715.605
232
I-1-02-i
15.336.144
15.796.228
16.102.951
16.409.674
233
I-1-02-ii
19.783.626
20.377.135
20.772.807
21.168.480
234
I-1-02-iii
24.384.469
25.116.003
25.603.693
26.091.382
235
I-1-03-i
9.444.543
9.727.879
9.916.770
10.105.661
236
I-1-03-ii
12.945.372
13.333.733
13.592.641
13.851.548
237
I-1-03-iii
18.986.546
19.556.142
19.935.873
20.315.604
238
I-1-04-i
11.522.066
11.867.728
12.098.169
12.328.610
239
I-1-04-ii
14.800.298
15.244.307
15.540.313
15.836.319
240
I-1-04-iii
31.551.163
32.497.698
33.128.721
33.759.744
241
I-1-05-i
20.297.838
20.906.773
21.312.730
21.718.686
242
I-1-05-ii
24.357.405
25.088.127
25.575.276
26.062.424
243
I-1-05-iii
33.515.636
34.521.105
35.191.418
35.861.731
244
I-1-06-i
9.567.951
9.854.989
10.046.348
10.237.707
245
I-1-06-ii
14.440.308
14.873.518
15.162.324
15.451.130
246
I-1-06-iii
18.589.840
19.147.535
19.519.332
19.891.128
12.582.579
12.960.057
13.211.708
13.463.360
15.523.168
15.988.863
16.299.326
16.609.790
16.935.675
17.443.745
17.782.459
18.121.172
2.393.513
2.465.319
2.513.189
2.561.059
2.661.348
2.741.188
2.794.415
2.847.642
3.541.442
3.647.686
3.718.515
3.789.343
7.335.711
7.555.782
7.702.496
7.849.211
10.178.641
10.484.001
10.687.573
10.891.146
247
I-1-07-i
248
I-1-07-ii
249
I-1-07-iii
250
I-1-11-i
251
I-1-11-ii
252
I-1-11-iii
253
I-1-12-i
254
I-1-12-ii

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
KATETERISASI RINGAN
KATETERISASI SEDANG
KATETERISASI BERAT
RINGAN
SEDANG
BERAT

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
- 913 No
Kode
INA-CBG
255
I-1-12-iii
256
I-1-13-i
257
I-1-13-ii
258
I-1-13-iii
259
I-1-14-i
260
I-1-14-ii
261
I-1-14-iii
262
I-1-15-i
263
I-1-15-ii
264
I-1-15-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
14.196.802
14.622.706
14.906.642
15.190.578
4.315.124
4.444.578
4.530.880
4.617.183
5.020.382
5.170.994
5.271.401
5.371.809
9.151.821
9.426.376
9.609.412
9.792.449
15.787.207
16.260.823
16.576.568
16.892.312
19.621.243
20.209.880
20.602.305
20.994.730
25.710.594
26.481.912
26.996.124
27.510.336
3.093.535
3.186.342
3.248.212
3.310.083
9.061.761
9.333.613
9.514.849
9.696.084
46.905.026
48.312.176
49.250.277
50.188.377
6.765.946
6.968.924
7.104.243
7.239.562
17.591.459
18.119.203
18.471.032
18.822.862
20.291.317
20.900.056
21.305.883
21.711.709
2.169.893
2.234.990
2.278.388
2.321.786
4.494.636
4.629.475
4.719.367
4.809.260
26.057.163
26.838.878
27.360.021
27.881.165
2.589.074
2.666.747
2.718.528
2.770.310
4.660.334
4.800.144
4.893.350
4.986.557
6.213.779
6.400.192
6.524.468
6.648.743
7.676.001
7.906.281
8.059.801
8.213.321
15.967.632
16.446.661
16.766.014
17.085.367
24.744.031
25.486.352
25.981.232
26.476.113
10.322.491
10.632.165
10.838.615
11.045.065
14.335.722
14.765.794
15.052.508
15.339.223
17.963.317
18.502.217
18.861.483
19.220.749

KOMPLEKS BERAT
KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

DARAH VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
265
I-1-16-i
266
I-1-16-ii
267
I-1-16-iii
268
I-1-17-i
269
I-1-17-ii
270
I-1-17-iii
271
I-1-20-i
272
I-1-20-ii
273
I-1-20-iii
274
I-1-30-i
275
I-1-30-ii
276
I-1-30-iii
277
I-1-40-i
278
I-1-40-ii
279
I-1-40-iii
280
I-4-10-i
3.002.080
3.092.143
3.152.184
3.212.226
281
I-4-10-ii
4.740.339
4.882.549
4.977.355
5.072.162
282
I-4-10-iii
6.838.352
7.043.502
7.180.269
7.317.036
283
I-4-11-i
3.559.682
3.666.473
3.737.666
3.808.860
- 914 No
Kode
INA-CBG
284
I-4-11-ii
285
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.405.120
4.537.274
4.625.376
4.713.479
I-4-11-iii
7.796.018
8.029.898
8.185.819
8.341.739
286
I-4-12-i
3.117.912
3.211.449
3.273.807
3.336.165
287
I-4-12-ii
4.449.251
4.582.728
4.671.713
4.760.698
288
I-4-12-iii
5.397.567
5.559.494
5.667.446
5.775.397
289
I-4-13-i
2.800.742
2.884.764
2.940.779
2.996.794
290
I-4-13-ii
4.068.906
4.190.973
4.272.351
4.353.729
291
I-4-13-iii
8.328.579
8.578.436
8.745.008
8.911.579
292
I-4-14-i
1.741.803
1.794.057
1.828.893
1.863.729
293
I-4-14-ii
2.038.167
2.099.312
2.140.075
2.180.838
294
I-4-14-iii
3.158.480
3.253.235
3.316.404
3.379.574
295
I-4-15-i
2.562.640
2.639.519
2.690.772
2.742.024
296
I-4-15-ii
3.668.546
3.778.602
3.851.973
3.925.344
297
I-4-15-iii
4.181.259
4.306.697
4.390.322
4.473.947
298
I-4-16-i
1.921.980
1.979.639
2.018.079
2.056.518
299
I-4-16-ii
3.114.867
3.208.313
3.270.611
3.332.908
300
I-4-16-iii
3.924.179
4.041.905
4.120.388
4.198.872
301
I-4-17-i
HIPERTENSI RINGAN
1.720.132
1.771.736
1.806.139
1.840.541
302
I-4-17-ii
HIPERTENSI SEDANG
2.435.878
2.508.955
2.557.672
2.606.390
303
I-4-17-iii
HIPERTENSI BERAT
2.963.362
3.052.263
3.111.530
3.170.798
304
I-4-18-i
2.533.260
2.609.258
2.659.923
2.710.589
305
I-4-18-ii
3.880.785
3.997.209
4.074.825
4.152.440
306
I-4-18-iii
5.231.921
5.388.878
5.493.517
5.598.155
307
I-4-19-i
1.982.608
2.042.087
2.081.739
2.121.391
308
I-4-19-ii
3.247.450
3.344.874
3.409.823
3.474.772
309
I-4-19-iii
3.870.931
3.987.059
4.064.478
4.141.896
310
I-4-20-i
2.406.176
2.478.361
2.526.485
2.574.608
311
I-4-20-ii
2.772.095
2.855.257
2.910.699
2.966.141
312
I-4-20-iii
3.679.031
3.789.402
3.862.982
3.936.563
313
I-4-21-i
3.199.825
3.295.819
3.359.816
3.423.812
314
I-4-21-ii
3.991.574
4.111.321
4.191.152
4.270.984
315
I-4-21-iii
5.445.353
5.608.714
5.717.621
5.826.528
316
I-4-22-i
2.082.145
2.144.609
2.186.252
2.227.895

VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT


RINGAN
SEDANG
KONGENITAL BERAT
RINGAN
SEDANG
BERAT
- 915 No
Kode
INA-CBG
317
I-4-22-ii
318
I-4-22-iii
319
I-4-23-i
320
I-4-23-ii
321
I-4-23-iii
322
I-4-24-i
323
I-4-24-ii
324
I-4-24-iii
325
J-1-01-i
326
J-1-01-ii
327
J-1-01-iii
328
J-1-02-i
329
J-1-02-ii
330
J-1-02-iii
331
J-1-10-i
332
J-1-10-ii
333
J-1-10-iii
334
J-1-20-i
335
J-1-20-ii
336
J-1-20-iii
337
J-1-30-i
338
J-1-30-ii
339
J-1-30-iii
340
J-4-10-i
341
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.399.254
2.471.232
2.519.217
2.567.202
3.500.446
3.605.460
3.675.469
3.745.478
1.577.342
1.624.662
1.656.209
1.687.756
1.936.613
1.994.711
2.033.443
2.072.175
3.783.964
3.897.483
3.973.163
4.048.842
1.881.314
1.937.753
1.975.379
2.013.006
4.697.120
4.838.033
4.931.976
5.025.918
5.938.659
6.116.819
6.235.592
6.354.365
15.450.441
15.913.954
16.222.963
16.531.972
16.828.984
17.333.853
17.670.433
18.007.013
27.664.717
28.494.658
29.047.953
29.601.247
7.748.042
7.980.484
8.135.445
8.290.405
8.300.218
8.549.224
8.715.229
8.881.233
12.265.357
12.633.318
12.878.625
13.123.932
3.023.398
3.114.100
3.174.568
3.235.036
7.302.605
7.521.684
7.667.736
7.813.788
12.930.160
13.318.065
13.576.668
13.835.271
2.613.183
2.691.579
2.743.843
2.796.106
3.800.669
3.914.689
3.990.702
4.066.716
5.715.032
5.886.483
6.000.784
6.115.085
1.762.214
1.815.080
1.850.325
1.885.569
8.630.248
8.889.156
9.061.761
9.234.365
26.028.449
26.809.303
27.329.872
27.850.441
2.033.830
2.094.845
2.135.522
2.176.198
J-4-10-ii
2.908.133
2.995.377
3.053.539
3.111.702
342
J-4-10-iii
4.399.571
4.531.558
4.619.549
4.707.541
343
J-4-11-i
1.283.088
1.321.581
1.347.242
1.372.904
344
J-4-11-ii
1.786.029
1.839.610
1.875.331
1.911.051
345
J-4-11-iii
2.559.426
2.636.208
2.687.397
2.738.585
346
J-4-12-i
EMBOLI PARU RINGAN
1.962.175
2.021.040
2.060.284
2.099.527
347
J-4-12-ii
EMBOLI PARU SEDANG
2.540.949
2.617.178
2.667.997
2.718.816

RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
- 916 No
Kode
INA-CBG
348
J-4-12-iii
349
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
EMBOLI PARU BERAT
3.393.181
3.494.976
3.562.840
3.630.704
J-4-13-i
3.022.494
3.113.169
3.173.619
3.234.069
350
J-4-13-ii
4.443.067
4.576.359
4.665.220
4.754.081
351
J-4-13-iii
7.223.762
7.440.474
7.584.950
7.729.425
352
J-4-14-i
TUMOR PARU RINGAN
2.059.734
2.121.526
2.162.721
2.203.916
353
J-4-14-ii
TUMOR PARU SEDANG
3.450.337
3.553.847
3.622.854
3.691.861
354
J-4-14-iii
TUMOR PARU BERAT
4.102.275
4.225.344
4.307.389
4.389.435
355
J-4-15-i
1.921.980
1.979.639
2.018.079
2.056.518
356
J-4-15-ii
3.478.104
3.582.447
3.652.009
3.721.571
357
J-4-15-iii
4.345.821
4.476.196
4.563.112
4.650.029
358
J-4-16-i
1.601.650
1.649.699
1.681.732
1.713.765
359
J-4-16-ii
2.242.310
2.309.579
2.354.425
2.399.271
360
J-4-16-iii
4.044.891
4.166.238
4.247.135
4.328.033
361
J-4-17-i
2.000.213
2.060.219
2.100.224
2.140.228
362
J-4-17-ii
2.702.631
2.783.710
2.837.763
2.891.815
363
J-4-17-iii
3.533.449
3.639.453
3.710.122
3.780.791
364
J-4-18-i
1.799.626
1.853.614
1.889.607
1.925.599
365
J-4-18-ii
2.505.800
2.580.974
2.631.090
2.681.206
366
J-4-18-iii
2.599.068
2.677.040
2.729.021
2.781.003
367
J-4-19-i
2.242.310
2.309.579
2.354.425
2.399.271
368
J-4-19-ii
2.562.640
2.639.519
2.690.772
2.742.024
369
J-4-19-iii
4.014.675
4.135.116
4.215.409
4.295.703
370
J-4-20-i
2.242.310
2.309.579
2.354.425
2.399.271
371
J-4-20-ii
2.735.203
2.817.260
2.871.964
2.926.668
372
J-4-20-iii
6.180.574
6.365.991
6.489.602
6.613.214
373
J-4-21-i
1.281.320
1.319.759
1.345.386
1.371.012
374
J-4-21-ii
3.161.250
3.256.087
3.319.312
3.382.537
375
J-4-21-iii
4.508.976
4.644.246
4.734.425
4.824.605
376
K-1-10-i
3.452.099
3.555.662
3.624.704
3.693.746
377
K-1-10-ii
4.817.631
4.962.160
5.058.513
5.154.865
378
K-1-10-iii
5.642.276
5.811.544
5.924.390
6.037.235
379
K-1-11-i
2.968.274
3.057.323
3.116.688
3.176.054
380
K-1-11-ii
3.896.986
4.013.896
4.091.835
4.169.775

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT

USUS BESAR (RINGAN)
USUS BESAR (SEDANG)
USUS BESAR (BERAT)
- 917 No
Kode
INA-CBG
381
K-1-11-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
9.889.784
10.186.477
10.384.273
10.582.069
1.596.704
1.644.606
1.676.540
1.708.474
2.081.000
2.143.430
2.185.050
2.226.670
4.139.546
4.263.733
4.346.523
4.429.314
382
K-1-12-i
383
K-1-12-ii
384
K-1-12-iii
385
K-1-13-i
1.813.637
1.868.047
1.904.319
1.940.592
386
K-1-13-ii
3.167.904
3.262.941
3.326.299
3.389.657
387
K-1-13-iii
3.387.959
3.489.597
3.557.357
3.625.116
2.930.945
3.018.874
3.077.493
3.136.112
3.442.727
3.546.009
3.614.864
3.683.718
8.476.993
8.731.303
8.900.843
9.070.383

RINGAN
SEDANG
BERAT
388
K-1-14-i
389
K-1-14-ii
390
K-1-14-iii
391
K-1-20-i
5.686.894
5.857.501
5.971.238
6.084.976
392
K-1-20-ii
7.937.404
8.175.526
8.334.274
8.493.022
393
K-1-20-iii
16.954.670
17.463.310
17.802.403
18.141.497
394
K-1-30-i
3.743.397
3.855.698
3.930.566
4.005.434
395
K-1-30-ii
6.904.198
7.111.324
7.249.408
7.387.492
396
K-1-30-iii
10.752.403
11.074.975
11.290.024
11.505.072
397
K-1-40-i
3.760.694
3.873.515
3.948.728
4.023.942
398
K-1-40-ii
4.138.270
4.262.418
4.345.183
4.427.949
399
K-1-40-iii
6.862.922
7.068.810
7.206.068
7.343.327
400
K-1-50-i
2.868.502
2.954.557
3.011.927
3.069.297
401
K-1-50-ii
3.714.845
3.826.291
3.900.588
3.974.884
402
K-1-50-iii
PROSEDUR ANAL BERAT
5.274.092
5.432.315
5.537.797
5.643.279
403
K-4-10-i
2.172.684
2.237.864
2.281.318
2.324.772
404
K-4-10-ii
2.599.744
2.677.736
2.729.731
2.781.726
405
K-4-10-iii
10.765.506
11.088.471
11.303.781
11.519.091
406
K-4-11-i
1.281.320
1.319.759
1.345.386
1.371.012
407
K-4-11-ii
1.921.980
1.979.639
2.018.079
2.056.518
408
K-4-11-iii
3.492.930
3.597.718
3.667.576
3.737.435
409
K-4-12-i
1.281.320
1.319.759
1.345.386
1.371.012
410
K-4-12-ii
1.914.272
1.971.700
2.009.986
2.048.271
411
K-4-12-iii
4.594.116
4.731.940
4.823.822
4.915.704
412
K-4-13-i

(RINGAN)
1.921.980
1.979.639
2.018.079
2.056.518

(RINGAN)
(SEDANG)
(BERAT)
- 918 No
Kode
INA-CBG
413
K-4-13-ii
414
K-4-13-iii
415
K-4-14-i
416
K-4-14-ii
417
K-4-14-iii
418
K-4-15-i
419
K-4-15-ii
420
K-4-15-iii
421
K-4-16-i
422
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.489.437
2.564.120
2.613.909
2.663.698
4.071.630
4.193.778
4.275.211
4.356.644
1.601.650
1.649.699
1.681.732
1.713.765
2.167.666
2.232.696
2.276.049
2.319.402
3.278.801
3.377.165
3.442.741
3.508.317
1.601.650
1.649.699
1.681.732
1.713.765
3.011.538
3.101.885
3.162.115
3.222.346
4.284.877
4.413.423
4.499.121
4.584.819
1.601.650
1.649.699
1.681.732
1.713.765
K-4-16-ii
1.921.980
1.979.639
2.018.079
2.056.518
423
K-4-16-iii
2.346.026
2.416.407
2.463.327
2.510.248
424
K-4-17-i
1.281.320
1.319.759
1.345.386
1.371.012
425
K-4-17-ii
1.869.470
1.925.554
1.962.943
2.000.332
426
K-4-17-iii
2.488.073
2.562.715
2.612.477
2.662.238
427
K-4-18-i
1.281.320
1.319.759
1.345.386
1.371.012
428
K-4-18-ii
1.989.140
2.048.814
2.088.597
2.128.380
429
K-4-18-iii
2.353.143
2.423.737
2.470.800
2.517.862
430
L-1-20-i
13.112.068
13.505.430
13.767.671
14.029.913
431
L-1-20-ii
13.640.165
14.049.370
14.322.173
14.594.977
432
L-1-20-iii
20.898.308
21.525.257
21.943.223
22.361.189
433
L-1-30-i
471.033
485.164
494.585
504.006
434
L-1-30-ii
682.294
702.762
716.408
730.054
435
L-1-30-iii
719.607
741.195
755.587
769.979
436
L-1-40-i
190.190
195.895
199.699
203.503
437
L-1-40-ii
428.060
440.902
449.463
458.024
438
L-1-40-iii
725.448
747.212
761.721
776.230
439
L-1-50-i
4.315.124
4.444.578
4.530.880
4.617.183
440
L-1-50-ii
7.767.223
8.000.240
8.155.584
8.310.929
441
L-1-50-iii
9.391.672
9.673.422
9.861.256
10.049.089
442
L-4-10-i
152.224
156.791
159.836
162.880
443
L-4-10-ii
177.595
182.923
186.475
190.027

(SEDANG)
RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
- 919 No
Kode
INA-CBG
444
L-4-10-iii
445
L-4-11-i
446
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
359.260
370.038
377.223
384.408
1.817.843
1.872.378
1.908.735
1.945.092
L-4-11-ii
2.490.413
2.565.125
2.614.933
2.664.742
447
L-4-11-iii
6.753.688
6.956.299
7.091.373
7.226.446
448
L-4-12-i
152.224
156.791
159.836
162.880
449
L-4-12-ii
223.349
230.049
234.516
238.983
450
L-4-12-iii
374.529
385.765
393.256
400.746
451
L-4-13-i
1.206.369
1.242.560
1.266.687
1.290.814
452
L-4-13-ii
1.391.014
1.432.745
1.460.565
1.488.385
453
L-4-13-iii
2.086.630
2.149.229
2.190.961
2.232.694
454
L-4-14-i
101.483
104.527
106.557
108.587
455
L-4-14-ii
152.224
156.791
159.836
162.880
456
L-4-14-iii
238.006
245.146
249.906
254.666
457
M-1-01-i
494.769
509.612
519.508
529.403
458
M-1-01-ii
552.242
568.810
579.855
590.899
459
M-1-01-iii
775.751
799.023
814.539
830.054
460
M-1-02-i
316.090
325.573
331.894
338.216
461
M-1-02-ii
518.960
534.528
544.907
555.287
462
M-1-02-iii
939.812
968.006
986.802
1.005.599
463
M-1-03-i
849.289
874.768
891.754
908.740
464
M-1-03-ii
1.020.118
1.050.721
1.071.124
1.091.526
465
M-1-03-iii
1.059.475
1.091.259
1.112.449
1.133.638
466
M-1-04-i
208.515
214.770
218.941
223.111
467
M-1-04-ii
267.314
275.334
280.680
286.026
468
M-1-04-iii
334.493
344.528
351.218
357.908
469
M-1-05-i
324.826
334.571
341.068
347.564
470
M-1-05-ii
375.412
386.675
394.183
401.691
471
M-1-05-iii
639.429
658.612
671.401
684.189
472
M-1-07-i
397.509
409.434
417.384
425.335
473
M-1-07-ii
532.538
548.514
559.165
569.815
474
M-1-07-iii
1.084.830
1.117.375
1.139.072
1.160.768
475
M-1-10-i
224.095
230.818
235.300
239.782


TULANG WAJAH RINGAN
- 920 No
Kode
INA-CBG
476
M-1-10-ii
477
M-1-10-iii
478
M-1-20-i
479
M-1-20-ii
480
M-1-20-iii
481
M-1-30-i
482
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
832.731
857.713
874.367
891.022
1.038.697
1.069.858
1.090.632
1.111.406
221.688
228.338
232.772
237.206
316.173
325.658
331.981
338.305
615.089
633.542
645.844
658.145
132.602
136.580
139.233
141.885
M-1-30-ii
273.990
282.210
287.690
293.170
483
M-1-30-iii
PROSEDUR KAKI BERAT
408.736
420.998
429.173
437.347
484
M-1-40-i
148.537
152.994
155.964
158.935
485
M-1-40-ii
273.413
281.615
287.084
292.552
486
M-1-40-iii
478.473
492.827
502.396
511.966
487
M-1-50-i
177.445
182.769
186.318
189.867
488
M-1-50-ii
357.202
367.918
375.062
382.206
489
M-1-50-iii
546.826
563.231
574.167
585.104
490
M-1-60-i
133.915
137.933
140.611
143.289
491
M-1-60-ii
268.099
276.142
281.504
286.866
492
M-1-60-iii
466.588
480.585
489.917
499.249
493
M-1-70-i
179.393
184.775
188.362
191.950
494
M-1-70-ii
366.050
377.032
384.353
391.674
495
M-1-70-iii
590.117
607.820
619.623
631.425
496
M-1-80-i
144.542
148.878
151.769
154.660
497
M-1-80-ii
218.518
225.073
229.444
233.814
498
M-1-80-iii
503.085
518.177
528.239
538.301
499
M-4-10-i
101.483
104.527
106.557
108.587
500
M-4-10-ii
152.224
156.791
159.836
162.880
501
M-4-10-iii
FRAKTUR FEMUR BERAT
296.576
305.473
311.405
317.336
502
M-4-11-i
126.854
130.659
133.196
135.734
503
M-4-11-ii
277.933
286.271
291.830
297.389
504
M-4-11-iii
493.325
508.125
517.991
527.858
505
M-4-12-i
101.483
104.527
106.557
108.587
506
M-4-12-ii
184.648
190.188
193.881
197.574

TULANG WAJAH SEDANG
TULANG WAJAH BERAT

RINGAN
SEDANG
BERAT

SELAIN KAKI (BERAT)

PANGGUL RINGAN
PANGGUL SEDANG
PANGGUL BERAT
PELVIS RINGAN
PELVIS SEDANG
- 921 No
Kode
INA-CBG
507
M-4-12-iii
508
M-4-13-i
509
M-4-13-ii
510
M-4-13-iii
511
M-4-14-i
512
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
333.570
343.578
350.249
356.920
168.991
174.061
177.441
180.821
253.707
261.319
266.393
271.467
502.706
517.788
527.842
537.896
192.405
198.177
202.025
205.873
M-4-14-ii
237.687
244.818
249.572
254.325
513
M-4-14-iii
OSTEOMIELITIS BERAT
356.030
366.711
373.831
380.952
514
M-4-15-i
114.223
117.649
119.934
122.218
515
M-4-15-ii
152.306
156.876
159.922
162.968
516
M-4-15-iii
431.303
444.242
452.868
461.494
517
M-4-16-i
126.854
130.659
133.196
135.734
518
M-4-16-ii
202.966
209.055
213.114
217.174
519
M-4-16-iii
340.425
350.637
357.446
364.254
520
M-4-17-i
126.854
130.659
133.196
135.734
521
M-4-17-ii
177.595
182.923
186.475
190.027
522
M-4-17-iii
248.021
255.462
260.422
265.383
523
M-4-18-i
134.124
138.148
140.830
143.513
524
M-4-18-ii
202.966
209.055
213.114
217.174
525
M-4-18-iii
227.467
234.291
238.840
243.389
526
M-4-19-i
99.723
102.715
104.709
106.704
527
M-4-19-ii
167.966
173.005
176.364
179.723
528
M-4-19-iii
328.049
337.891
344.452
351.013
529
M-4-20-i
101.483
104.527
106.557
108.587
530
M-4-20-ii
152.224
156.791
159.836
162.880
531
M-4-20-iii
168.701
173.762
177.136
180.510
532
M-4-21-i
101.483
104.527
106.557
108.587
533
M-4-21-ii
126.854
130.659
133.196
135.734
534
M-4-21-iii
291.249
299.986
305.811
311.636
535
N-1-01-i
3.466.905
3.570.912
3.640.250
3.709.588
536
N-1-01-ii
4.688.911
4.829.578
4.923.356
5.017.134
537
N-1-01-iii
9.941.885
10.240.142
10.438.980
10.637.817

PELVIS BERAT

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
RINGAN
SEDANG
BERAT
ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
- 922 No
Kode
INA-CBG
538
N-1-11-i
539
N-1-11-ii
540
N-1-11-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.782.863
4.926.349
5.022.006
5.117.663
6.468.714
6.662.776
6.792.150
6.921.524
13.715.598
14.127.066
14.401.378
14.675.690
2.589.074
2.666.747
2.718.528
2.770.310
6.023.298
6.203.997
6.324.463
6.444.929
10.977.837
11.307.172
11.526.728
11.746.285
541
N-1-12-i
542
N-1-12-ii
543
N-1-12-iii
544
N-1-20-i
3.505.402
3.610.564
3.680.672
3.750.780
545
N-1-20-ii
6.949.967
7.158.466
7.297.465
7.436.464
546
N-1-20-iii
7.950.132
8.188.636
8.347.638
8.506.641
547
N-1-30-i
4.170.295
4.295.404
4.378.809
4.462.215
548
N-1-30-ii
6.337.283
6.527.401
6.654.147
6.780.893
549
N-1-30-iii
7.295.258
7.514.115
7.660.021
7.805.926
550
N-1-40-i
3.757.844
3.870.579
3.945.736
4.020.893
551
N-1-40-ii
5.093.891
5.246.708
5.348.586
5.450.464
552
N-1-40-iii
5.924.343
6.102.073
6.220.560
6.339.047
553
N-4-10-i
1.601.650
1.649.699
1.681.732
1.713.765
554
N-4-10-ii
2.144.654
2.208.993
2.251.887
2.294.780
555
N-4-10-iii
4.694.261
4.835.089
4.928.974
5.022.859
556
N-4-11-i
1.226.548
1.263.345
1.287.876
1.312.407
557
N-4-11-ii
2.072.837
2.135.022
2.176.479
2.217.936
558
N-4-11-iii
2.402.475
2.474.549
2.522.598
2.570.648
559
N-4-12-i
1.281.320
1.319.759
1.345.386
1.371.012
560
N-4-12-ii
1.921.980
1.979.639
2.018.079
2.056.518
561
N-4-12-iii
3.191.118
3.286.852
3.350.674
3.414.496
562
N-4-13-i
BATU URIN RINGAN
1.690.455
1.741.168
1.774.977
1.808.787
563
N-4-13-ii
BATU URIN SEDANG
2.038.053
2.099.194
2.139.955
2.180.716
564
N-4-13-iii
BATU URIN BERAT
5.019.165
5.169.740
5.270.123
5.370.506
1.109.860
1.143.156
1.165.353
1.187.551
1.709.045
1.760.317
1.794.498
1.828.679
2.771.527
2.854.673
2.910.103
2.965.534
565
N-4-14-i
566
N-4-14-ii
567
N-4-14-iii

URIN BAWAH RINGAN
URIN BAWAH SEDANG
URIN BAWAH BERAT
RINGAN
SEDANG
BERAT
GINJAL RINGAN
GINJAL SEDANG
GINJAL BERAT

(RINGAN)
(SEDANG)
(BERAT)
- 923 No
Kode
INA-CBG
568
N-4-15-i
569
N-4-15-ii
570
N-4-15-iii
571
N-4-16-i
572
N-4-16-ii
573
N-4-16-iii
574
O-6-10-i
575
O-6-10-ii
576
O-6-10-iii
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
584
585
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.646.565
1.695.961
1.728.893
1.761.824
2.259.599
2.327.387
2.372.579
2.417.771
2.578.610
2.655.968
2.707.541
2.759.113
2.137.013
2.201.124
2.243.864
2.286.604
2.562.640
2.639.519
2.690.772
2.742.024
5.388.850
5.550.515
5.658.292
5.766.069
3.155.406
3.250.068
3.313.176
3.376.284
3.502.981
3.608.071
3.678.130
3.748.190
3.926.884
4.044.690
4.123.228
4.201.766
1.649.128
1.698.602
1.731.584
1.764.567
2.115.680
2.179.151
2.221.464
2.263.778
3.585.422
3.692.984
3.764.693
3.836.401
1.436.068
1.479.150
1.507.872
1.536.593
1.724.714
1.776.456
1.810.950
1.845.444
2.166.856
2.231.862
2.275.199
2.318.536
1.439.199
1.482.375
1.511.159
1.539.943
O-6-13-ii
2.121.097
2.184.730
2.227.152
2.269.574
O-6-13-iii
2.506.809
2.582.014
2.632.150
2.682.286
32.194.235
33.160.062
33.803.947
34.447.832
39.835.330
41.030.390
41.827.097
42.623.803
46.755.511
48.158.176
49.093.286
50.028.397
39.005.829
40.176.004
40.956.120
41.736.237
44.743.701
46.086.012
46.980.886
47.875.760
51.122.877
52.656.563
53.679.021
54.701.479
2.157.562
2.222.289
2.265.440
2.308.591
3.020.587
3.111.204
3.171.616
3.232.028
4.758.109
4.900.853
4.996.015
5.091.177
19.268.544
19.846.601
20.231.972
20.617.342
25.006.416
25.756.609
26.256.737
26.756.865
586
P-8-01-i
587
P-8-01-ii
588
P-8-01-iii
589
P-8-02-i
590
P-8-02-ii
591
P-8-02-iii
592
P-8-03-i
593
P-8-03-ii
594
P-8-03-iii
595
P-8-04-i
596
P-8-04-ii

SALURAN URIN RINGAN
SALURAN URIN SEDANG
SALURAN URIN BERAT
RINGAN
SEDANG
BERAT
&KURET RINGAN
KURET SEDANG
KURET BERAT

- 924 No
Kode
INA-CBG
597
P-8-04-iii
598
P-8-05-i
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii
603
P-8-06-iii
604
P-8-07-i
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
614
P-8-11-ii
615
P-8-11-iii
616
P-8-12-i
617
P-8-12-ii
618
P-8-12-iii
619
P-8-13-i
620
P-8-13-ii
621
P-8-13-iii
622
P-8-14-i
623
P-8-14-ii
624
P-8-14-iii
Deskripsi (INA-CBG)
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
RINGAN
SEDANG
BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
35.852.906
36.928.494
37.645.552
38.362.610
10.477.610
10.791.938
11.001.490
11.211.042
14.850.599
15.296.117
15.593.129
15.890.141
21.880.364
22.536.775
22.974.382
23.411.990
1.726.050
1.777.831
1.812.352
1.846.873
4.343.193
4.473.489
4.560.353
4.647.217
8.078.835
8.321.200
8.482.776
8.644.353
3.020.587
3.111.204
3.171.616
3.232.028
8.468.998
8.723.068
8.892.448
9.061.828
11.219.323
11.555.902
11.780.289
12.004.675
2.188.964
2.254.633
2.298.413
2.342.192
3.107.543
3.200.769
3.262.920
3.325.071
4.386.896
4.518.503
4.606.241
4.693.979
1.358.031
1.398.772
1.425.932
1.453.093
1.967.305
2.026.325
2.065.671
2.105.017
3.862.400
3.978.272
4.055.520
4.132.768
3.824.792
3.939.536
4.016.032
4.092.528
8.142.878
8.387.164
8.550.022
8.712.879
8.313.472
8.562.877
8.729.146
8.895.416
1.804.437
1.858.570
1.894.658
1.930.747
2.805.586
2.889.753
2.945.865
3.001.977
3.309.998
3.409.298
3.475.498
3.541.697
932.630
960.609
979.262
997.914
1.725.825
1.777.599
1.812.116
1.846.632
2.581.155
2.658.590
2.710.213
2.761.836
1.704.012
1.755.133
1.789.213
1.823.293
3.479.111
3.583.484
3.653.066
3.722.648
3.816.571
3.931.069
4.007.400
4.083.731
- 925 No
Kode
INA-CBG
625
P-8-15-i
626
P-8-15-ii
627
P-8-15-iii
628
P-8-16-i
629
P-8-16-ii
630
P-8-16-iii
631
P-8-17-i
632
P-8-17-ii
633
P-8-17-iii
634
S-4-10-i
635
S-4-10-ii
636
S-4-10-iii
637
S-4-11-i
638
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.281.470
1.319.914
1.345.544
1.371.173
2.561.322
2.638.162
2.689.388
2.740.615
3.008.669
3.098.930
3.159.103
3.219.276
1.160.034
1.194.835
1.218.035
1.241.236
1.645.557
1.694.924
1.727.835
1.760.746
2.136.014
2.200.094
2.242.815
2.285.535
765.620
788.588
803.901
819.213
2.543.129
2.619.423
2.670.286
2.721.148
5.133.144
5.287.139
5.389.802
5.492.464
1.281.320
1.319.759
1.345.386
1.371.012
1.601.650
1.649.699
1.681.732
1.713.765
2.081.870
2.144.326
2.185.963
2.227.601
800.825
824.850
840.866
856.883
S-4-11-ii
1.218.871
1.255.437
1.279.814
1.304.192
639
S-4-11-iii
1.971.919
2.031.077
2.070.515
2.109.954
640
S-4-12-i
960.990
989.820
1.009.039
1.028.259
641
S-4-12-ii
1.281.320
1.319.759
1.345.386
1.371.012
642
S-4-12-iii
2.502.519
2.577.595
2.627.645
2.677.695
643
S-4-13-i
1.281.320
1.319.759
1.345.386
1.371.012
644
S-4-13-ii
2.265.086
2.333.039
2.378.340
2.423.642
645
S-4-13-iii
4.612.003
4.750.363
4.842.604
4.934.844
646
S-4-14-i
780.685
804.105
819.719
835.333
647
S-4-14-ii
1.658.436
1.708.189
1.741.358
1.774.526
648
S-4-14-iii
3.144.986
3.239.335
3.302.235
3.365.135
649
S-4-15-i
590.439
608.152
619.961
631.770
650
S-4-15-ii
1.114.359
1.147.790
1.170.077
1.192.365
651
S-4-15-iii
1.443.354
1.486.655
1.515.522
1.544.389
652
S-4-16-i
LUKA BAKAR RINGAN
2.242.310
2.309.579
2.354.425
2.399.271
653
S-4-16-ii
LUKA BAKAR SEDANG
3.166.872
3.261.878
3.325.215
3.388.553
654
S-4-16-iii
LUKA BAKAR BERAT
5.654.941
5.824.589
5.937.688
6.050.787
1.195.643
1.231.513
1.255.426
1.279.339
1.601.650
1.649.699
1.681.732
1.713.765
655
S-4-17-i
656
S-4-17-ii

ASPIRASI RINGAN
ASPIRASI SEDANG
ASPIRASI BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT

PASIEN RINGAN
PASIEN SEDANG
PASIEN BERAT

- 926 No
Kode
INA-CBG
657
S-4-17-iii
658
T-1-10-i
659
T-1-10-ii
660
T-1-10-iii
661
T-4-10-i
662
T-4-10-ii
663
T-4-10-iii
664
T-4-11-i
665
T-4-11-ii
666
T-4-11-iii
667
T-4-12-i
668
T-4-12-ii
669
T-4-12-iii
670
U-1-10-i
671
U-1-10-ii
672
U-1-10-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.611.806
2.690.160
2.742.396
2.794.632
1.234.234
1.271.261
1.295.946
1.320.630
1.657.493
1.707.217
1.740.367
1.773.517
3.015.519
3.105.985
3.166.295
3.226.606
539.889
556.086
566.884
577.681
1.028.909
1.059.776
1.080.355
1.100.933
1.495.755
1.540.627
1.570.542
1.600.457
533.919
549.937
560.615
571.294
840.237
865.444
882.249
899.054
1.353.375
1.393.976
1.421.044
1.448.111
1.121.155
1.154.790
1.177.213
1.199.636
1.694.564
1.745.401
1.779.292
1.813.183
2.636.132
2.715.216
2.767.939
2.820.662
1.193.367
1.229.168
1.253.035
1.276.902
2.435.138
2.508.192
2.556.895
2.605.598
10.515.418
10.830.880
11.041.188
11.251.497
5.178.149
5.333.493
5.437.056
5.540.619
6.904.198
7.111.324
7.249.408
7.387.492
11.599.668
11.947.658
12.179.651
12.411.645

DOKTER RINGAN
DOKTER SEDANG
DOKTER BERAT

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
673
U-1-11-i
674
U-1-11-ii
675
U-1-11-iii
676
U-1-12-i
3.164.423
3.259.355
3.322.644
3.385.932
677
U-1-12-ii
7.767.223
8.000.240
8.155.584
8.310.929
678
U-1-12-iii
10.085.886
10.388.463
10.590.181
10.791.899
679
U-1-13-i
3.452.099
3.555.662
3.624.704
3.693.746
680
U-1-13-ii
3.894.905
4.011.752
4.089.650
4.167.548
681
U-1-13-iii
7.510.474
7.735.789
7.885.998
8.036.208
1.904.760
1.961.903
1.999.998
2.038.093
2.337.523
2.407.649
2.454.400
2.501.150
2.770.031
2.853.132
2.908.532
2.963.933

682
U-1-14-i
683
U-1-14-ii
684
U-1-14-iii
685
U-1-15-i
1.118.738
1.152.300
1.174.675
1.197.050
686
U-1-15-ii
1.589.649
1.637.338
1.669.131
1.700.924
687
U-1-15-iii
3.132.467
3.226.441
3.289.090
3.351.739
- 927 No
Kode
INA-CBG
688
U-1-20-i
689
U-1-20-ii
690
U-1-20-iii
691
U-1-30-i
692
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.893.688
2.980.499
3.038.373
3.096.246
5.150.765
5.305.288
5.408.303
5.511.318
12.707.125
13.088.339
13.342.481
13.596.624
2.482.280
2.556.748
2.606.394
2.656.039
U-1-30-ii
3.351.078
3.451.610
3.518.632
3.585.653
693
U-1-30-iii
6.569.076
6.766.148
6.897.530
7.028.911
694
U-4-10-i
2.310.588
2.379.905
2.426.117
2.472.329
695
U-4-10-ii
5.792.158
5.965.923
6.081.766
6.197.610
696
U-4-10-iii
8.449.498
8.702.983
8.871.973
9.040.963
697
U-4-11-i
1.281.320
1.319.759
1.345.386
1.371.012
698
U-4-11-ii
1.921.980
1.979.639
2.018.079
2.056.518
699
U-4-11-iii
2.658.090
2.737.833
2.790.995
2.844.157
700
U-4-12-i
1.281.320
1.319.759
1.345.386
1.371.012
701
U-4-12-ii
1.493.724
1.538.536
1.568.410
1.598.284
702
U-4-12-iii
2.374.953
2.446.202
2.493.701
2.541.200
703
U-4-13-i
1.258.802
1.296.566
1.321.742
1.346.918
704
U-4-13-ii
1.463.431
1.507.334
1.536.603
1.565.871
705
U-4-13-iii
1.661.619
1.711.468
1.744.700
1.777.932
706
U-4-14-i
1.601.650
1.649.699
1.681.732
1.713.765
707
U-4-14-ii
1.921.980
1.979.639
2.018.079
2.056.518
708
U-4-14-iii
3.219.650
3.316.239
3.380.632
3.445.025
709
U-4-15-i
1.281.320
1.319.759
1.345.386
1.371.012
710
U-4-15-ii
1.601.650
1.649.699
1.681.732
1.713.765
711
U-4-15-iii
2.242.744
2.310.027
2.354.882
2.399.736
712
V-1-10-i
3.745.723
3.858.094
3.933.009
4.007.923
713
V-1-10-ii
4.315.124
4.444.578
4.530.880
4.617.183
714
V-1-10-iii
8.198.736
8.444.698
8.608.672
8.772.647
715
V-1-11-i
4.315.124
4.444.578
4.530.880
4.617.183
716
V-1-11-ii
4.815.751
4.960.223
5.056.538
5.152.853
717
V-1-11-iii
7.131.390
7.345.331
7.487.959
7.630.587
2.330.514
2.400.429
2.447.040
2.493.650
8.906.450
9.173.643
9.351.772
9.529.901
10.399.092
10.711.065
10.919.046
11.127.028
718
V-1-12-i
719
V-1-12-ii
720
V-1-12-iii


DAN TELINGA RINGAN
DAN TELINGA SEDANG
DAN TELINGA BERAT


KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

- 928 No
Kode
INA-CBG
721
V-1-13-i
722
V-1-13-ii
723
V-1-13-iii
724
V-1-14-i
725
V-1-14-ii
726
V-1-14-iii
727
V-1-15-i
728
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.532.304
3.638.273
3.708.919
3.779.565
6.712.391
6.913.763
7.048.010
7.182.258
10.356.298
10.666.987
10.874.113
11.081.239
4.258.233
4.385.980
4.471.145
4.556.310
6.193.235
6.379.033
6.502.897
6.626.762
8.418.803
8.671.367
8.839.743
9.008.119
2.007.520
2.067.746
2.107.896
2.148.046
V-1-15-ii
3.823.935
3.938.653
4.015.131
4.091.610
729
V-1-15-iii
6.722.404
6.924.076
7.058.524
7.192.972
730
V-4-10-i
3.232.614
3.329.592
3.394.245
3.458.897
731
V-4-10-ii
4.175.307
4.300.566
4.384.072
4.467.578
732
V-4-10-iii
7.979.744
8.219.137
8.378.732
8.538.326
733
V-4-11-i
1.643.905
1.693.222
1.726.100
1.758.979
734
V-4-11-ii
2.402.008
2.474.068
2.522.109
2.570.149
735
V-4-11-iii
3.963.154
4.082.049
4.161.312
4.240.575
736
W-1-01-i
4.833.886
4.978.903
5.075.581
5.172.258
737
W-1-01-ii
5.822.187
5.996.852
6.113.296
6.229.740
738
W-1-01-iii
12.860.054
13.245.856
13.503.057
13.760.258
739
W-1-10-i
1.346.232
1.386.618
1.413.543
1.440.468
740
W-1-10-ii
2.512.289
2.587.658
2.637.903
2.688.149
741
W-1-10-iii
4.109.308
4.232.587
4.314.773
4.396.959
742
W-1-11-i
1.398.287
1.440.235
1.468.201
1.496.167
743
W-1-11-ii
2.696.773
2.777.676
2.831.612
2.885.547
744
W-1-11-iii
5.178.149
5.333.493
5.437.056
5.540.619
745
W-1-12-i
1.270.554
1.308.670
1.334.081
1.359.493
746
W-1-12-ii
1.444.595
1.487.933
1.516.825
1.545.717
747
W-1-12-iii
2.219.080
2.285.653
2.330.035
2.374.416
748
W-1-13-i
1.512.259
1.557.627
1.587.872
1.618.117
749
W-1-13-ii
1.641.878
1.691.134
1.723.972
1.756.809
750
W-1-13-iii
2.205.345
2.271.505
2.315.612
2.359.719
751
W-1-20-i
4.120.476
4.244.090
4.326.499
4.408.909
752
W-1-20-ii
5.796.067
5.969.949
6.085.871
6.201.792

NON KOMPLEK (BERAT)

RINGAN
SEDANG
BERAT

SERVIK RINGAN
SERVIK SEDANG
SERVIK BERAT
ENDOSKOP RINGAN
ENDOSKOP SEDANG
ENDOSKOP BERAT
- 929 No
Kode
INA-CBG
753
W-1-20-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
7.322.067
7.541.729
7.688.170
7.834.611
2.249.367
2.316.848
2.361.835
2.406.822
3.587.856
3.695.492
3.767.249
3.839.006
9.540.992
9.827.222
10.018.042
10.208.861
754
W-1-30-i
755
W-1-30-ii
756
W-1-30-iii
757
W-4-10-i
1.677.464
1.727.788
1.761.337
1.794.886
758
W-4-10-ii
2.267.280
2.335.299
2.380.644
2.425.990
759
W-4-10-iii
5.125.279
5.279.038
5.381.543
5.484.049
760
W-4-11-i
1.601.650
1.649.699
1.681.732
1.713.765
761
W-4-11-ii
2.562.640
2.639.519
2.690.772
2.742.024
762
W-4-11-iii
3.114.367
3.207.798
3.270.085
3.332.372
1.281.320
1.319.759
1.345.386
1.371.012
1.761.815
1.814.669
1.849.906
1.885.142
1.964.228
2.023.155
2.062.439
2.101.724

763
W-4-12-i
764
W-4-12-ii
765
W-4-12-iii
766
W-4-13-i
ABORTUS RINGAN
702.691
723.772
737.825
751.879
767
W-4-13-ii
ABORTUS SEDANG
960.990
989.820
1.009.039
1.028.259
768
W-4-13-iii
ABORTUS BERAT
1.281.320
1.319.759
1.345.386
1.371.012
769
W-4-14-i
960.990
989.820
1.009.039
1.028.259
770
W-4-14-ii
1.235.988
1.273.068
1.297.788
1.322.507
771
W-4-14-iii
1.555.251
1.601.909
1.633.014
1.664.119
772
W-4-15-i
801.354
825.394
841.421
857.448
773
W-4-15-ii
891.258
917.996
935.821
953.646
774
W-4-15-iii
1.234.031
1.271.052
1.295.733
1.320.414
775
W-4-16-i
960.990
989.820
1.009.039
1.028.259
776
W-4-16-ii
1.281.320
1.319.759
1.345.386
1.371.012
777
W-4-16-iii
1.746.905
1.799.312
1.834.251
1.869.189
778
W-4-17-i
784.894
808.441
824.139
839.837
779
W-4-17-ii
1.281.320
1.319.759
1.345.386
1.371.012
780
W-4-17-iii
2.424.002
2.496.722
2.545.202
2.593.682
781
Z-4-10-i
REHABILITASI RINGAN
2.198.593
2.264.551
2.308.523
2.352.495
782
Z-4-10-ii
REHABILITASI SEDANG
2.918.315
3.005.864
3.064.231
3.122.597
783
Z-4-10-iii
REHABILITASI BERAT
4.145.745
4.270.117
4.353.032
4.435.947
784
Z-4-11-i
1.919.130
1.976.704
2.015.086
2.053.469
785
Z-4-11-ii
2.310.208
2.379.514
2.425.719
2.471.923
786
Z-4-11-iii
3.655.160
3.764.815
3.837.918
3.911.021
- 930 No
Kode
INA-CBG
787
Z-4-12-i
788
Z-4-12-ii
789
Z-4-12-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
960.990
989.820
1.009.039
1.028.259
1.957.985
2.016.725
2.055.884
2.095.044
2.488.289
2.562.938
2.612.704
2.662.469
- 931 b. RawatJalan
No
Kode
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
749.845
772.341
787.338
802.335
972.667
1.001.847
1.021.300
1.040.753
1.808.802
1.863.066
1.899.242
1.935.418
1.494.799
1.539.643
1.569.539
1.599.435
1.248.776
1.286.239
1.311.215
1.336.190
437.826
450.961
459.718
468.474
976.295
1.005.584
1.025.110
1.044.636
B-3-12-0

200.597
206.615
210.627
214.638
C-3-10-0
547.199
563.615
574.559
585.503
10
C-3-11-0

KANDUNG KEMIH
865.416
891.379
908.687
925.995
11
C-3-12-0
196.188
202.074
205.997
209.921
190.512
196.227
200.038
203.848
1.621.832
1.670.487
1.702.924
1.735.360
1.486.474
1.531.068
1.560.797
1.590.527

LAPAROSKOPI
PANKREAS
LAPAROSKOPI
EMPEDU

OVARIUM
GASTROINTESTINAL
GINJAL ATAU PROSTAT
12
C-3-13-0
13
C-3-14-0
14
C-3-15-0
15
C-3-16-0
337.096
347.209
353.951
360.693
16
C-3-17-0

LEHER
223.620
230.328
234.801
239.273
17
C-3-18-0
99.143
102.118
104.101
106.083
18
C-3-19-0

MYELOMA ATAU TESTIS
140.209
144.415
147.219
150.024
19
C-3-20-0
2.792.265
2.876.033
2.931.878
2.987.724
20
C-3-21-0
160.003
164.804
168.004
171.204
21
C-3-22-0
702.500
723.575
737.625
751.675
22
C-3-23-0
113.790
117.203
119.479
121.755
23
D-2-10-0

TULANG
964.042
992.964
1.012.244
1.031.525
24
D-2-11-0
PROSEDUR LIMPA
1.207.146
1.243.360
1.267.503
1.291.646
25
D-2-21-0
1.012.453
1.042.827
1.063.076
1.083.325
26
D-2-22-0
222.203
228.869
233.313
237.757
27
D-3-10-0
160.947
165.776
168.995
172.213
28
D-3-11-0
417.865
430.401
438.758
447.116
29
E-2-10-0
247.874
255.311
260.268
265.226
30
E-2-21-0
179.700
185.092
188.686
192.280
31
E-2-22-0
179.700
185.092
188.686
192.280

TYMUS
TYMUS
TULANG
PEMBENTUK DARAH
PARATIROID
THYROGLOSSAL
- 932 No
Kode
INA-CBG
32
E-3-10-0
33
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

ENDOKRIN
208.980
215.249
219.429
223.609
F-3-10-0
TERAPI SHOCK
291.520
300.266
306.096
311.927
34
F-5-10-0
357.207
367.923
375.067
382.211
35
F-5-11-0
TERAPI KELOMPOK
235.545
242.611
247.322
252.033
36
F-5-12-0
301.420
310.463
316.491
322.519
37
F-5-13-0
255.283
262.941
268.047
273.152
38
F-5-14-0
171.261
176.398
179.824
183.249
39
F-5-15-0
160.664
165.484
168.698
171.911
40
F-5-16-0
167.347
172.368
175.715
179.062
41
G-2-10-0
140.919
145.147
147.965
150.784
42
G-2-11-0
1.221.549
1.258.195
1.282.626
1.307.057
43
G-2-12-0

EKSTRAKRANIAL
1.770.325
1.823.434
1.858.841
1.894.247
44
G-2-13-0
434.300
447.329
456.015
464.701
45
G-2-21-0
792.090
815.853
831.695
847.537
46
G-2-22-0
718.889
740.456
754.834
769.211
47
G-2-31-0
1.186.230
1.221.817
1.245.541
1.269.266
48
G-2-32-0
608.060
626.302
638.463
650.625
49
G-3-10-0
241.343
248.583
253.410
258.237
50
G-3-11-0
321.423
331.065
337.494
343.922
51
G-3-12-0
526.657
542.456
552.989
563.522
52
G-3-13-0
526.717
542.518
553.052
563.587
53
H-2-21-0
691.237
711.974
725.799
739.624
54
H-2-22-0
179.700
185.092
188.686
192.280
55
H-2-23-0
179.700
185.092
188.686
192.280
56
H-2-31-0
1.144.977
1.179.326
1.202.226
1.225.126
57
H-2-32-0
119.165
122.740
125.124
127.507
58
H-2-33-0
179.700
185.092
188.686
192.280
59
H-2-34-0
513.665
529.075
539.348
549.621
60
H-2-35-0
169.264
174.342
177.727
181.113
61
H-2-36-0
913.648
941.058
959.331
977.604
62
H-2-37-0

972.619
1.001.797
1.021.250
1.040.702
63
H-3-10-0
338.400
348.552
355.320
362.088
64
H-3-11-0
177.961
183.300
186.859
190.418

AKUT
MENTAL
PROSEDUR KRANIOTOMI

MATA
MATA
MATA
MATA
MATA
- 933 No
Kode
INA-CBG
65
H-3-12-0
66
H-3-13-0
67
I-2-11-0
68
I-2-12-0
69
I-2-13-0
70
I-2-14-0
71
I-2-15-0
Deskripsi (INA-CBG)
MATA
TORASIK
ABDOMEN
PENGGANTIAN ALAT
DARAH VENA
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
185.800
191.374
195.090
198.806
180.401
185.813
189.421
193.029
2.080.408
2.142.820
2.184.428
2.226.036
1.462.754
1.506.636
1.535.891
1.565.147
1.859.072
1.914.844
1.952.026
1.989.207
3.290.162
3.388.866
3.454.670
3.520.473
197.864
203.800
207.757
211.714
2.078.153
2.140.498
2.182.061
2.223.624
685.107
705.661
719.363
733.065
72
I-2-16-0
73
I-2-17-0
74
I-2-21-0
1.604.039
1.652.160
1.684.241
1.716.322
75
I-2-22-0
1.510.484
1.555.798
1.586.008
1.616.217
76
I-2-23-0
309.116
318.389
324.572
330.754
77
I-2-31-0
2.404.099
2.476.222
2.524.304
2.572.386
78
I-2-32-0
3.143.712
3.238.024
3.300.898
3.363.772
79
I-2-41-0
2.107.898
2.171.135
2.213.293
2.255.451
80
I-2-42-0

LAIN
2.450.780
2.524.303
2.573.319
2.622.335
81
I-3-10-0
PROSEDUR RESUSITASI
311.105
320.438
326.660
332.882
82
I-3-11-0
164.200
169.126
172.410
175.694
83
I-3-12-0
954.271
982.899
1.001.984
1.021.070
84
I-3-13-0
313.419
322.822
329.090
335.359
85
I-3-14-0
200.891
206.918
210.936
214.954
177.961
183.300
186.859
190.418
1.101.820
1.134.875
1.156.911
1.178.948
177.613
182.942
186.494
190.046
895.060
921.912
939.813
957.714
1.160.973
1.195.802
1.219.021
1.242.241

PACU JANTUNG

KARDIOVASKULAR
PERNAFASAN
PENDEK
86
I-3-15-0
87
J-2-10-0
88
J-2-21-0
89
J-2-22-0
90
J-2-31-0
PROSEDUR
91
J-2-32-0
863.956
889.875
907.154
924.433
92
J-3-10-0
179.700
185.092
188.686
192.280
93
J-3-11-0

PADA DADA
507.802
523.036
533.192
543.348
94
J-3-12-0
196.188
202.074
205.997
209.921
95
J-3-13-0
288.740
297.402
303.177
308.952
96
J-3-14-0
306.529
315.725
321.855
327.986
- 934 No
Kode
INA-CBG
97
J-3-15-0
98
J-3-16-0
99
J-3-17-0
100
K-2-10-0
101
K-2-11-0
102
K-2-12-0

103
K-2-13-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
268.801
276.865
282.241
287.617
306.529
315.725
321.855
327.986
179.700
185.092
188.686
192.280
517.240
532.757
543.102
553.446
1.104.517
1.137.653
1.159.743
1.181.834
847.860
873.295
890.253
907.210
1.379.937
1.421.336
1.448.934
1.476.533
179.700
185.092
188.686
192.280
179.700
185.092
188.686
192.280
2.309.579
2.378.867
2.425.058
2.471.250
776.594
799.892
815.424
830.956
179.700
185.092
188.686
192.280

PERNAFASAN
KECIL

FEMORALIS
USUS BESAR
ATAS
ATAS
104
K-2-14-0
105
K-2-21-0
106
K-2-22-0
107
K-2-31-0
108
K-2-32-0
109
K-2-41-0
855.435
881.098
898.206
915.315
110
K-2-42-0

244.408
251.740
256.629
261.517
111
K-2-51-0
566.863
583.869
595.206
606.543
112
K-2-52-0
309.116
318.389
324.572
330.754
113
K-2-53-0
179.700
185.092
188.686
192.280
114
K-3-10-0

GASTROINTESTINAL
341.958
352.217
359.056
365.895
115
K-3-11-0
205.584
211.751
215.863
219.974
116
K-3-12-0
208.488
214.742
218.912
223.082
117
K-3-13-0
179.700
185.092
188.686
192.280
481.601
496.049
505.681
515.313
232.572
239.549
244.201
248.852
308.173
317.418
323.581
329.745
1.059.509
1.091.294
1.112.484
1.133.674
679.138
699.512
713.095
726.677
306.529
315.725
321.855
327.986
309.116
318.389
324.572
330.754

GASTROINTESTINAL
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
118
K-3-14-0
119
K-3-15-0
120
K-3-16-0
121
L-2-21-0
122
L-2-22-0
123
L-2-31-0
124
L-2-32-0
125
L-2-41-0
925.611
953.379
971.892
990.404
126
L-2-42-0

207.600
213.828
217.980
222.132
127
L-2-51-0
1.385.785
1.427.358
1.455.074
1.482.790
L-2-52-0

1.060.171
1.091.976
1.113.180
1.134.383
128
- 935 No
Kode
INA-CBG
129
L-2-53-0
130
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

179.700
185.092
188.686
192.280
L-3-10-0
244.408
251.740
256.629
261.517
131
L-3-11-0
237.337
244.457
249.204
253.951
132
L-3-12-0
180.755
186.178
189.793
193.408
133
M-2-10-0
1.417.759
1.460.291
1.488.647
1.517.002
134
M-2-21-0
1.269.701
1.307.792
1.333.186
1.358.580
135
M-2-22-0
309.116
318.389
324.572
330.754
136
M-2-31-0
PROSEDUR BUNION
771.216
794.352
809.777
825.201
137
M-2-32-0
244.408
251.740
256.629
261.517
138
M-2-41-0

TULANG
244.408
251.740
256.629
261.517
139
M-2-42-0
84.230
86.757
88.441
90.126
140
M-2-51-0
179.700
185.092
188.686
192.280
141
M-2-52-0
179.700
185.092
188.686
192.280
142
M-2-61-0
PROSEDUR ARTROSKOPI
880.806
907.230
924.847
942.463
143
M-2-62-0
179.700
185.092
188.686
192.280
885.571
912.138
929.850
947.561
1.207.736
1.243.968
1.268.123
1.292.277
179.700
185.092
188.686
192.280
891.627
918.375
936.208
954.040
860.458
886.271
903.481
920.690

DAN WAJAH
PAHA
PAHA

TULANG
WAJAH
WAJAH
BAWAH
BAWAH
144
M-2-63-0
145
M-2-64-0
146
M-2-65-0
147
M-2-71-0
148
M-2-72-0
149
M-2-81-0
1.283.126
1.321.619
1.347.282
1.372.944
150
M-2-82-0
932.108
960.072
978.714
997.356
151
M-2-83-0
179.700
185.092
188.686
192.280
152
M-2-84-0
179.700
185.092
188.686
192.280
153
M-3-10-0
512.900
528.287
538.545
548.803
154
M-3-11-0
284.372
292.903
298.590
304.278
155
M-3-12-0
643.085
662.377
675.239
688.101
156
M-3-13-0
209.663
215.953
220.146
224.339
157
M-3-14-0

TERTUTUP
358.350
369.100
376.267
383.434
158
M-3-15-0
157.875
162.611
165.769
168.926
159
M-3-16-0

179.700
185.092
188.686
192.280
160
M-3-17-0
196.188
202.074
205.997
209.921
161
N-2-11-0
2.374.020
2.445.241
2.492.721
2.540.201

PERGELANGAN TANGAN
PERGELANGAN TANGAN
MUSKULOSKELETAL
SKELETAL
- 936 No
Kode
INA-CBG
162
N-2-12-0
163
N-2-21-0
164
N-2-22-0
165
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.373.347
1.414.548
1.442.014
1.469.481
1.366.108
1.407.091
1.434.413
1.461.736
309.116
318.389
324.572
330.754
N-2-23-0
309.116
318.389
324.572
330.754
166
N-2-24-0
998.959
1.028.928
1.048.907
1.068.886
167
N-2-31-0
840.961
866.190
883.010
899.829
168
N-2-32-0
309.116
318.389
324.572
330.754
169
N-2-41-0
309.116
318.389
324.572
330.754
170
N-2-42-0
522.774
538.457
548.913
559.368
171
N-3-10-0
309.116
318.389
324.572
330.754
172
N-3-11-0
358.155
368.900
376.063
383.226
173
N-3-12-0
276.762
285.065
290.600
296.135
174
N-3-13-0
309.116
318.389
324.572
330.754
175
N-3-14-0
265.977
273.957
279.276
284.596
176
N-3-15-0
682.033
702.494
716.135
729.775
177
O-7-10-0
113.870
117.286
119.564
121.841
178
O-7-11-0
627.113
645.926
658.469
671.011
179
O-7-12-0
228.353
235.204
239.771
244.338
180
O-7-13-0
126.909
130.716
133.254
135.792
181
P-9-10-0
169.264
174.342
177.727
181.113
182
P-9-11-0
169.264
174.342
177.727
181.113
183
P-9-12-0
169.264
174.342
177.727
181.113
184
P-9-13-0
169.264
174.342
177.727
181.113
185
P-9-14-0
169.264
174.342
177.727
181.113
186
P-9-15-0
107.893
111.129
113.287
115.445
187
P-9-16-0
169.264
174.342
177.727
181.113
188
P-9-17-0
168.536
173.592
176.963
180.334
189
Q-5-10-0
220.605
227.223
231.635
236.048
190
Q-5-11-0
165.338
170.298
173.604
176.911
191
Q-5-12-0
GIGI
145.724
150.096
153.010
155.925
192
Q-5-13-0
MEDICAL CHECK-UP
110.744
114.066
116.281
118.496
193
Q-5-14-0
121.855
125.510
127.947
130.384


DAN URETHRA
DAN URETHRA
TRANSURETHRA
TRANSURETHRA
SALURAN KEMIH
KEMIH
KEMIH
PROSEDUR DIALISIS
CAESAR
VAGINAL/JALAN LAHIR

ASPIRASI
- 937 No
Kode
INA-CBG
194
Q-5-15-0
195
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
83.799
86.313
87.989
89.665
Q-5-16-0
VAKSINASI
94.713
97.554
99.448
101.342
196
Q-5-17-0
PASANG INFUS
81.924
84.382
86.020
87.659
197
Q-5-18-0
154.206
158.833
161.917
165.001
198
Q-5-19-0
172.394
177.565
181.013
184.461
199
Q-5-20-0
ABORSI MENGANCAM
115.550
119.016
121.327
123.638
200
Q-5-21-0
ABORSI
113.976
117.395
119.675
121.954
201
Q-5-22-0
121.855
125.510
127.947
130.384
202
Q-5-23-0
149.182
153.658
156.641
159.625
203
Q-5-24-0
101.889
104.946
106.984
109.022
204
Q-5-25-0
158.894
163.661
166.839
170.017
205
Q-5-26-0
BRONKIAL AKUT
224.904
231.651
236.149
240.647
206
Q-5-27-0
160.053
164.854
168.055
171.256
207
Q-5-28-0
129.879
133.775
136.372
138.970
208
Q-5-29-0

JANTUNG LAIN-LAIN
367.708
378.739
386.093
393.447
209
Q-5-30-0
426.133
438.917
447.440
455.963
210
Q-5-31-0
FRAKTUR
152.027
156.588
159.629
162.669
211
Q-5-32-0
SALURAN KEMIH AKUT
176.082
181.364
184.886
188.408
212
Q-5-33-0
HEMATOLOGI AKUT
184.357
189.888
193.575
197.262
213
Q-5-34-0
INFEKSI VIRUS HIV
261.892
269.749
274.987
280.225
214
Q-5-35-0
INFEKSI AKUT
296.979
305.888
311.828
317.767
215
Q-5-36-0
345.851
356.226
363.143
370.060
216
Q-5-37-0

SHOCK
176.402
181.694
185.222
188.750
217
Q-5-38-0
PARU AKUT
235.237
242.294
246.999
251.704
218
Q-5-39-0
150.534
155.051
158.061
161.072
219
Q-5-40-0
147.698
152.129
155.083
158.037
220
Q-5-41-0
204.468
210.602
214.691
218.780
221
Q-5-42-0
160.311
165.120
168.326
171.532
222
Q-5-43-0
230.857
237.782
242.400
247.017
223
Q-5-44-0
188.411
194.063
197.832
201.600
224
T-2-10-0

TERAPI DETOKSIKASI
97.726
100.657
102.612
104.566
225
U-2-10-0
1.304.259
1.343.387
1.369.472
1.395.557
226
U-2-11-0

LEHER
1.550.257
1.596.765
1.627.770
1.658.775
227
U-2-12-0
170.569
175.686
179.097
182.509
- 938 No
Kode
INA-CBG
228
U-2-13-0
229
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
223.620
230.328
234.801
239.273
U-2-14-0
415.384
427.846
436.153
444.461
230
U-2-15-0
236.012
243.093
247.813
252.533
231
U-2-21-0
274.917
283.165
288.663
294.162
232
U-2-22-0
531.163
547.097
557.721
568.344
233
U-2-23-0
695.995
716.874
730.794
744.714
234
U-2-24-0
586.572
604.169
615.901
627.632
235
U-2-25-0
223.620
230.328
234.801
239.273
236
U-2-31-0
179.700
185.092
188.686
192.280
237
U-2-32-0
223.620
230.328
234.801
239.273
238
U-3-10-0
213.792
220.206
224.482
228.758
239
U-3-11-0
226.981
233.790
238.330
242.869
240
U-3-12-0
100.371
103.382
105.389
107.397
241
U-3-13-0
220.622
227.241
231.654
236.066
242
U-3-14-0
202.707
208.788
212.842
216.896
243
U-3-15-0
176.778
182.082
185.617
189.153
244
U-3-16-0
PROSEDUR PADA GIGI
199.374
205.355
209.342
213.330
245
V-2-10-0

PROSTAT
1.945.121
2.003.474
2.042.377
2.081.279
246
V-2-11-0
219.360
225.941
230.328
234.715
700.009
721.010
735.010
749.010
309.116
318.389
324.572
330.754
309.116
318.389
324.572
330.754

(RHINOPLASTY)

RONGGA HIDUNG
TENGGOROKAN
PROSEDUR PADA PENIS

SKROTUM
SKROTUM
TRANSURETHRAL
247
V-2-12-0
248
V-2-13-0
249
V-2-14-0
250
V-2-15-0
SIRKUMSISI/SUNAT
169.264
174.342
177.727
181.113
251
V-3-10-0
353.012
363.602
370.662
377.723
252
V-3-11-0
746.803
769.207
784.143
799.079
253
V-3-12-0
431.149
444.083
452.706
461.329
254
W-2-10-0
157.875
162.611
165.769
168.926
255
W-2-11-0
403.469
415.573
423.643
431.712
256
W-2-12-0
746.803
769.207
784.143
799.079
257
W-2-13-0
119.774
123.367
125.763
128.158
258
W-2-21-0
1.501.273
1.546.311
1.576.336
1.606.362
259
W-2-22-0
157.875
162.611
165.769
168.926

PROSEDUR ABORSI
RAHIM & LEHER RAHIM
TERHALANG/TERGANGGU
TERHALANG/TERGANGGU
PANGGUL TERBUKA
PANGGUL TERBUKA
- 939 No
Kode
INA-CBG
260
W-2-23-0
Deskripsi (INA-CBG)
JALAN LAHIR
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
526.836
542.641
553.178
563.715
1.729.443
1.781.326
1.815.915
1.850.504
1.212.937
1.249.325
1.273.584
1.297.842
261
W-2-31-0
262
W-2-32-0
263
W-2-33-0
515.514
530.980
541.290
551.600
264
W-2-34-0
175.335
180.595
184.102
187.609
265
W-3-10-0
426.133
438.917
447.440
455.962
266
W-3-11-0
340.638
350.858
357.670
364.483
267
W-3-12-0
157.875
162.611
165.769
168.926
268
Z-3-10-0
1.787.354
1.840.975
1.876.722
1.912.469
269
Z-3-11-0

EMPEDU
1.366.108
1.407.091
1.434.413
1.461.736
270
Z-3-12-0
228.107
234.950
239.512
244.074
271
Z-3-13-0

LAIN-LAIN
1.391.971
1.433.731
1.461.570
1.489.409
272
Z-3-14-0
DIAGNOSTIK TIDUR
275.236
283.493
288.998
294.502
273
Z-3-15-0
179.700
185.092
188.686
192.280
274
Z-3-16-0

(MRI)
576.784
594.088
605.623
617.159
275
Z-3-17-0
PENGOBATAN NUKLIR
242.146
249.411
254.254
259.097
276
Z-3-18-0
CT-SCAN KEPALA
233.303
240.302
244.969
249.635
277
Z-3-19-0
CT SCAN LAIN-LAIN
242.823
250.108
254.965
259.821
278
Z-3-20-0
165.150
170.105
173.408
176.711
279
Z-3-21-0
157.875
162.611
165.769
168.926
280
Z-3-22-0
177.990
183.329
186.889
190.449
281
Z-3-23-0
185.392
190.953
194.661
198.369
282
Z-3-24-0
364.258
375.186
382.471
389.756
283
Z-3-25-0
162.240
167.107
170.352
173.597
284
Z-3-26-0
183.363
188.864
192.531
196.199
285
Z-3-27-0
PERAWATAN LUKA
175.062
180.314
183.815
187.316
286
Z-3-28-0
IMAGING PAYUDARA
179.700
185.092
188.686
192.280
287
Z-3-29-0
IMAGING LAIN-LAIN
517.929
533.467
543.826
554.184
288
Z-3-30-0
FOTOTERAPI
87.407
90.029
91.778
93.526
- 940 -
3. RUMAH SAKIT MATA KLAS D

a. RawatInap
No
Kode
INA-CBG
A-4-10-i
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
SEPTIKEMIA RINGAN
1.817.415
1.871.937
1.908.286
1.944.634
A-4-10-ii
SEPTIKEMIA SEDANG
2.080.451
2.142.865
2.184.474
2.226.083
A-4-10-iii
SEPTIKEMIA BERAT
3.261.755
3.359.608
3.424.843
3.490.078
A-4-11-i
3.266.319
3.364.308
3.429.634
3.494.961
A-4-11-ii
5.046.085
5.197.467
5.298.389
5.399.311
A-4-11-iii
8.254.292
8.501.921
8.667.007
8.832.093
A-4-12-i
DEMAM RINGAN
1.281.320
1.319.759
1.345.386
1.371.012
A-4-12-ii
DEMAM SEDANG
1.837.776
1.892.909
1.929.665
1.966.420
A-4-12-iii
DEMAM BERAT
2.103.200
2.166.296
2.208.360
2.250.424
10
A-4-13-i
1.601.650
1.649.699
1.681.732
1.713.765
11
A-4-13-ii
1.921.980
1.979.639
2.018.079
2.056.518
12
A-4-13-iii
2.335.939
2.406.017
2.452.736
2.499.455
1.281.320
1.319.759
1.345.386
1.371.012
2.035.004
2.096.054
2.136.754
2.177.454
2.317.303
2.386.822
2.433.168
2.479.514

LAIN-LAIN RINGAN
LAIN-LAIN SEDANG
LAIN-LAIN BERAT
13
A-4-14-i
14
A-4-14-ii
15
A-4-14-iii
16
A-4-15-i
INFEKSI HIV RINGAN
1.921.980
1.979.639
2.018.079
2.056.518
17
A-4-15-ii
INFEKSI HIV SEDANG
2.882.970
2.969.459
3.027.118
3.084.778
18
A-4-15-iii
INFEKSI HIV BERAT
4.009.532
4.129.817
4.210.008
4.290.199
19
B-1-01-i
21.308.142
21.947.386
22.373.549
22.799.712
20
B-1-01-ii
23.508.577
24.213.835
24.684.006
25.154.178
21
B-1-01-iii
41.238.882
42.476.049
43.300.826
44.125.604
22
B-1-10-i
2.762.528
2.845.404
2.900.655
2.955.905
23
B-1-10-ii
7.040.253
7.251.460
7.392.265
7.533.070
24
B-1-10-iii
12.254.294
12.621.923
12.867.009
13.112.095
1.888.549
1.945.205
1.982.976
2.020.747
4.740.436
4.882.649
4.977.458
5.072.267
5.943.331
6.121.630
6.240.497
6.359.364
4.028.343
4.149.193
4.229.760
4.310.327
8.633.725
8.892.736
9.065.411
9.238.085
25
B-1-11-i
26
B-1-11-ii
27
B-1-11-iii
28
B-1-12-i
29
B-1-12-ii

(RINGAN)
(SEDANG)
(BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
- 941 No
Kode
INA-CBG
30
B-1-12-iii
31
B-1-13-i
32
B-1-13-ii
33
B-1-13-iii
34
B-1-14-i
35
B-1-14-ii
36
B-1-14-iii
37
B-4-10-i
38
B-4-10-ii
39
B-4-10-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
10.507.568
10.822.795
11.032.947
11.243.098
2.639.684
2.718.874
2.771.668
2.824.461
4.299.661
4.428.651
4.514.645
4.600.638
6.338.908
6.529.075
6.655.853
6.782.631
3.584.505
3.692.040
3.763.730
3.835.420
3.986.692
4.106.293
4.186.027
4.265.761
6.236.706
6.423.808
6.548.542
6.673.276
1.002.468
1.032.542
1.052.591
1.072.641
1.601.650
1.649.699
1.681.732
1.713.765
2.448.732
2.522.194
2.571.169
2.620.144
2.421.352
2.493.993
2.542.420
2.590.847
3.681.060
3.791.491
3.865.113
3.938.734
3.964.629
4.083.568
4.162.861
4.242.153
2.124.570
2.188.308
2.230.799
2.273.290
3.012.118
3.102.482
3.162.724
3.222.966
5.854.322
6.029.952
6.147.038
6.264.125
1.921.980
1.979.639
2.018.079
2.056.518
2.999.355
3.089.335
3.149.323
3.209.310
4.552.384
4.688.956
4.780.003
4.871.051
1.921.980
1.979.639
2.018.079
2.056.518
2.242.310
2.309.579
2.354.425
2.399.271
2.991.467
3.081.211
3.141.040
3.200.869

LAPAROSKOPIK BERAT
LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT

PANCREAS RINGAN
PANCREAS SEDANG
PANCREAS BERAT
(RINGAN)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT
40
B-4-11-i
41
B-4-11-ii
42
B-4-11-iii
43
B-4-12-i
44
B-4-12-ii
45
B-4-12-iii
46
B-4-13-i
47
B-4-13-ii
48
B-4-13-iii
49
B-4-14-i
50
B-4-14-ii
51
B-4-14-iii
52
C-4-10-i
1.871.620
1.927.769
1.965.201
2.002.634
53
C-4-10-ii
3.636.362
3.745.453
3.818.180
3.890.907
54
C-4-10-iii
LEUKEMIA AKUT BERAT
6.086.269
6.268.857
6.390.583
6.512.308
55
C-4-11-i
1.921.980
1.979.639
2.018.079
2.056.518
56
C-4-11-ii
2.562.640
2.639.519
2.690.772
2.742.024
57
C-4-11-iii
4.356.787
4.487.491
4.574.627
4.661.763
58
C-4-12-i
RADIOTERAPI RINGAN
1.281.320
1.319.759
1.345.386
1.371.012
59
C-4-12-ii
RADIOTERAPI SEDANG
3.527.860
3.633.696
3.704.253
3.774.811
60
C-4-12-iii
RADIOTERAPI BERAT
7.162.263
7.377.131
7.520.377
7.663.622
61
C-4-13-i
KEMOTERAPI RINGAN
1.281.320
1.319.759
1.345.386
1.371.012
- 942 No
Kode
INA-CBG
62
C-4-13-ii
63
C-4-13-iii
64
C-4-14-i
65
C-4-14-ii
66
C-4-14-iii
67
D-1-10-i
68
D-1-10-ii
69
D-1-10-iii
70
D-1-11-i
71
72
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
KEMOTERAPI SEDANG
2.562.640
2.639.519
2.690.772
2.742.024
KEMOTERAPI BERAT
3.353.024
3.453.615
3.520.676
3.587.736
1.661.529
1.711.375
1.744.605
1.777.836
2.427.932
2.500.770
2.549.329
2.597.888
3.701.313
3.812.352
3.886.378
3.960.405
13.634.763
14.043.806
14.316.501
14.589.196
20.766.789
21.389.793
21.805.129
22.220.465
28.144.674
28.989.014
29.551.908
30.114.801
2.802.508
2.886.584
2.942.634
2.998.684
D-1-11-ii
7.309.456
7.528.740
7.674.929
7.821.118
D-1-11-iii
10.356.298
10.666.987
10.874.113
11.081.239
3.452.099
3.555.662
3.624.704
3.693.746
7.767.223
8.000.240
8.155.584
8.310.929
14.040.542
14.461.758
14.742.569
15.023.380

RINGAN
SEDANG
BERAT
TULANG RINGAN
TULANG SEDANG
TULANG BERAT

73
D-1-20-i
74
D-1-20-ii
75
D-1-20-iii
76
D-4-10-i
1.230.786
1.267.710
1.292.326
1.316.941
77
D-4-10-ii
2.485.189
2.559.745
2.609.449
2.659.153
78
D-4-10-iii
3.203.300
3.299.399
3.363.465
3.427.531
79
D-4-11-i
2.802.887
2.886.974
2.943.031
2.999.089
80
D-4-11-ii
5.009.514
5.159.799
5.259.989
5.360.179
81
D-4-11-iii
6.858.324
7.064.074
7.201.240
7.338.407
82
D-4-12-i
1.642.987
1.692.277
1.725.136
1.757.996
83
D-4-12-ii
2.278.985
2.347.354
2.392.934
2.438.513
84
D-4-12-iii
3.499.382
3.604.364
3.674.351
3.744.339
1.281.320
1.319.759
1.345.386
1.371.012
1.921.980
1.979.639
2.018.079
2.056.518
2.242.310
2.309.579
2.354.425
2.399.271
1.543.834
1.590.149
1.621.026
1.651.903
3.604.475
3.712.609
3.784.699
3.856.788
4.299.640
4.428.629
4.514.622
4.600.615
3.071.459
3.163.603
3.225.032
3.286.461
4.023.319
4.144.019
4.224.485
4.304.952
9.118.946
9.392.515
9.574.894
9.757.272
3.129.652
3.223.542
3.286.135
3.348.728
85
D-4-13-i
86
D-4-13-ii
87
D-4-13-iii
88
D-4-14-i
89
D-4-14-ii
90
D-4-14-iii
91
E-1-01-i
92
E-1-01-ii
93
E-1-01-iii
94
E-1-10-i

RINGAN
SEDANG
BERAT
- 943 No
Kode
INA-CBG
95
E-1-10-ii
96
E-1-10-iii
97
E-1-20-i
98
E-1-20-ii
99
E-1-20-iii
100
E-4-10-i
101
E-4-10-ii
102
E-4-10-iii
103
E-4-11-i
104
E-4-11-ii
105
E-4-11-iii
106
E-4-12-i
107
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.798.663
3.912.623
3.988.597
4.064.570
8.006.464
8.246.658
8.406.787
8.566.917
3.624.202
3.732.928
3.805.412
3.877.896
4.854.033
4.999.654
5.096.735
5.193.816
10.755.166
11.077.821
11.292.924
11.508.028
1.601.650
1.649.699
1.681.732
1.713.765
2.277.883
2.346.220
2.391.777
2.437.335
4.354.129
4.484.753
4.571.835
4.658.918
1.366.542
1.407.539
1.434.869
1.462.200
2.585.263
2.662.821
2.714.526
2.766.232
4.263.218
4.391.115
4.476.379
4.561.644
1.632.827
1.681.812
1.714.468
1.747.125
E-4-12-ii
2.836.528
2.921.624
2.978.355
3.035.085
108
E-4-12-iii
4.631.833
4.770.788
4.863.425
4.956.062
109
E-4-13-i
1.722.313
1.773.982
1.808.429
1.842.875
110
E-4-13-ii
2.957.223
3.045.940
3.105.085
3.164.229
111
E-4-13-iii
5.116.743
5.270.246
5.372.580
5.474.915
112
F-4-10-i
SCHIZOFRENIA RINGAN
2.105.853
2.169.029
2.211.146
2.253.263
113
F-4-10-ii
SCHIZOFRENIA SEDANG
2.338.618
2.408.776
2.455.549
2.502.321
114
F-4-10-iii
SCHIZOFRENIA BERAT
3.462.375
3.566.247
3.635.494
3.704.742
115
F-4-11-i
1.941.087
1.999.319
2.038.141
2.076.963
116
F-4-11-ii
2.261.550
2.329.397
2.374.628
2.419.859
117
F-4-11-iii
DEPRESI MAYOR BERAT
2.900.134
2.987.138
3.045.141
3.103.143
118
F-4-12-i
119
F-4-12-ii
120
F-4-12-iii
121

RINGAN
SEDANG
BERAT

RINGAN
SEDANG
BERAT

IMPULSE RINGAN
IMPULSE SEDANG
IMPULSE BERAT
960.990
989.820
1.009.039
1.028.259
1.372.157
1.413.322
1.440.765
1.468.208
2.976.665
3.065.965
3.125.498
3.185.031
F-4-13-i
1.568.693
1.615.754
1.647.128
1.678.501
122
F-4-13-ii
2.077.353
2.139.673
2.181.220
2.222.767
123
F-4-13-iii
2.678.481
2.758.835
2.812.405
2.865.975
124
F-4-14-i
DEPRESI RINGAN
1.098.085
1.131.028
1.152.989
1.174.951
125
F-4-14-ii
DEPRESI SEDANG
1.408.517
1.450.772
1.478.943
1.507.113
126
F-4-14-iii
DEPRESI BERAT
1.895.222
1.952.079
1.989.983
2.027.888
127
F-4-15-i
1.305.561
1.344.727
1.370.839
1.396.950
- 944 No
Kode
INA-CBG
128
F-4-15-ii
129
F-4-15-iii
130
F-4-16-i
131
F-4-16-ii
132
F-4-16-iii
133
F-4-17-i
134
F-4-17-ii
135
F-4-17-iii
136
F-4-18-i
137
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.921.980
1.979.639
2.018.079
2.056.518
2.531.365
2.607.306
2.657.933
2.708.561
2.811.922
2.896.280
2.952.518
3.008.757
3.268.789
3.366.853
3.432.229
3.497.604
4.363.288
4.494.187
4.581.452
4.668.718
649.240
668.717
681.702
694.686
1.902.859
1.959.945
1.998.002
2.036.059
2.030.211
2.091.117
2.131.721
2.172.326
2.437.279
2.510.398
2.559.143
2.607.889
F-4-18-ii
2.681.696
2.762.147
2.815.781
2.869.414
138
F-4-18-iii
4.134.068
4.258.090
4.340.771
4.423.453
139
F-4-19-i
1.869.163
1.925.238
1.962.622
2.000.005
140
F-4-19-ii
2.393.512
2.465.317
2.513.187
2.561.058
141
F-4-19-iii
2.979.954
3.069.353
3.128.952
3.188.551
5.942.469
6.120.743
6.239.593
6.358.442
10.058.345
10.360.095
10.561.262
10.762.429
19.471.833
20.055.988
20.445.424
20.834.861

RINGAN
SEDANG
BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT
142
G-1-01-i
143
G-1-01-ii
144
G-1-01-iii
145
G-1-10-i
2.965.592
3.054.560
3.113.871
3.173.183
146
G-1-10-ii
4.186.678
4.312.279
4.396.012
4.479.746
147
G-1-10-iii
4.962.108
5.110.971
5.210.214
5.309.456
148
G-1-11-i
3.420.899
3.523.526
3.591.944
3.660.362
149
G-1-11-ii
7.025.073
7.235.825
7.376.327
7.516.828
150
G-1-11-iii
14.709.865
15.151.161
15.445.358
15.739.555
2.660.451
2.740.265
2.793.474
2.846.683
6.090.838
6.273.563
6.395.380
6.517.197
10.742.903
11.065.190
11.280.048
11.494.906

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT
151
G-1-12-i
152
G-1-12-ii
153
G-1-12-iii
154
G-1-13-i
701.644
722.693
736.726
750.759
155
G-1-13-ii
1.884.539
1.941.075
1.978.765
2.016.456
156
G-1-13-iii
4.252.313
4.379.882
4.464.928
4.549.975
3.352.395
3.452.967
3.520.015
3.587.063
4.529.195
4.665.071
4.755.655
4.846.239
11.089.202
11.421.878
11.643.662
11.865.446
4.275.678
4.403.948
4.489.462
4.574.975
157
G-1-20-i
158
G-1-20-ii
159
G-1-20-iii
160
G-1-30-i

RINGAN
SEDANG
BERAT
- 945 No
Kode
INA-CBG
161
G-1-30-ii
162
G-1-30-iii
163
G-4-10-i
164
G-4-10-ii
165
G-4-10-iii
166
G-4-11-i
167
G-4-11-ii
168
G-4-11-iii
169
G-4-12-i
170
G-4-12-ii
171
G-4-12-iii
172
G-4-13-i
173
G-4-13-ii
174
G-4-13-iii
175
G-4-14-i
176
G-4-14-ii
177
G-4-14-iii
178
G-4-15-i
179
G-4-15-ii
180
G-4-15-iii
181
G-4-16-i
182
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
11.159.929
11.494.727
11.717.926
11.941.125
14.366.278
14.797.266
15.084.592
15.371.917
1.921.980
1.979.639
2.018.079
2.056.518
2.242.310
2.309.579
2.354.425
2.399.271
3.425.627
3.528.396
3.596.909
3.665.421
3.171.129
3.266.263
3.329.685
3.393.108
3.678.509
3.788.865
3.862.435
3.936.005
5.390.919
5.552.647
5.660.465
5.768.283
2.371.725
2.442.877
2.490.312
2.537.746
2.988.374
3.078.025
3.137.793
3.197.560
4.340.257
4.470.465
4.557.270
4.644.075
1.319.612
1.359.200
1.385.593
1.411.985
2.242.310
2.309.579
2.354.425
2.399.271
2.650.728
2.730.250
2.783.265
2.836.279
2.413.374
2.485.775
2.534.042
2.582.310
3.970.814
4.089.939
4.169.355
4.248.771
4.971.550
5.120.696
5.220.127
5.319.558
2.470.158
2.544.263
2.593.666
2.643.069
2.984.816
3.074.360
3.134.057
3.193.753
3.688.418
3.799.071
3.872.839
3.946.607
1.601.650
1.649.699
1.681.732
1.713.765
G-4-16-ii
2.395.282
2.467.140
2.515.046
2.562.952
183
G-4-16-iii
4.347.008
4.477.419
4.564.359
4.651.299
184
G-4-17-i
2.288.904
2.357.571
2.403.349
2.449.127
185
G-4-17-ii
2.840.631
2.925.850
2.982.662
3.039.475
186
G-4-17-iii
4.760.920
4.903.748
4.998.966
5.094.185
187
G-4-18-i
1.921.980
1.979.639
2.018.079
2.056.518
188
G-4-18-ii
2.755.786
2.838.460
2.893.576
2.948.691
189
G-4-18-iii
2.919.475
3.007.059
3.065.449
3.123.838
190
G-4-19-i
1.601.650
1.649.699
1.681.732
1.713.765

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
DEGENERATIF RINGAN
DEGENERATIF SEDANG
DEGENERATIF BERAT
RINGAN
SEDANG
BERAT
TRAUMATIK RINGAN
TRAUMATIK SEDANG
TRAUMATIK BERAT
DENGAN INFARK BERAT
TANPA INFARK RINGAN
TANPA INFARK SEDANG
TANPA INFARK BERAT

PERIFER RINGAN
PERIFER SEDANG
PERIFER BERAT
PERSARAFAN RINGAN
PERSARAFAN SEDANG
PERSARAFAN BERAT
- 946 No
Kode
INA-CBG
191
G-4-19-ii
192
G-4-19-iii
193
G-4-20-i
194
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.245.959
3.343.337
3.408.257
3.473.176
4.841.940
4.987.198
5.084.037
5.180.876
1.121.155
1.154.790
1.177.213
1.199.636
G-4-20-ii
1.592.041
1.639.802
1.671.643
1.703.484
195
G-4-20-iii
2.714.803
2.796.247
2.850.543
2.904.839
196
G-4-21-i
1.299.162
1.338.137
1.364.120
1.390.103
197
G-4-21-ii
2.690.695
2.771.415
2.825.229
2.879.043
198
G-4-21-iii
3.169.956
3.265.054
3.328.453
3.391.852
199
G-4-22-i
1.281.320
1.319.759
1.345.386
1.371.012
200
G-4-22-ii
1.601.650
1.649.699
1.681.732
1.713.765
201
G-4-22-iii
1.837.511
1.892.636
1.929.387
1.966.137
202
G-4-23-i
1.281.320
1.319.759
1.345.386
1.371.012
203
G-4-23-ii
1.601.650
1.649.699
1.681.732
1.713.765
204
G-4-23-iii
2.289.445
2.358.128
2.403.917
2.449.706
205
G-4-24-i
1.281.320
1.319.759
1.345.386
1.371.012
206
G-4-24-ii
1.601.650
1.649.699
1.681.732
1.713.765
207
G-4-24-iii
TRAUMA KEPALA BERAT
3.365.694
3.466.665
3.533.978
3.601.292
208
G-4-25-i
GEGAR OTAK RINGAN
1.217.504
1.254.029
1.278.379
1.302.729
209
G-4-25-ii
GEGAR OTAK SEDANG
1.532.864
1.578.850
1.609.508
1.640.165
210
G-4-25-iii
GEGAR OTAK BERAT
1.999.964
2.059.963
2.099.962
2.139.962
211
G-4-26-i
1.921.980
1.979.639
2.018.079
2.056.518
212
G-4-26-ii
2.242.310
2.309.579
2.354.425
2.399.271
213
G-4-26-iii
4.280.256
4.408.663
4.494.268
4.579.873
214
H-1-20-i
1.661.311
1.711.151
1.744.377
1.777.603
215
H-1-20-ii
3.029.589
3.120.477
3.181.069
3.241.660
216
H-1-20-iii
4.120.052
4.243.653
4.326.054
4.408.455
217
H-1-30-i
1.626.582
1.675.379
1.707.911
1.740.443
218
H-1-30-ii
1.854.303
1.909.932
1.947.019
1.984.105
219
H-1-30-iii
3.093.838
3.186.653
3.248.530
3.310.407
220
H-4-10-i
1.921.980
1.979.639
2.018.079
2.056.518
221
H-4-10-ii
3.203.300
3.299.399
3.363.465
3.427.531
222
H-4-10-iii
5.222.324
5.378.994
5.483.441
5.587.887
223
H-4-11-i
1.281.320
1.319.759
1.345.386
1.371.012

SEDANG

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)

RINGAN
SEDANG
- 947 No
Kode
INA-CBG
224
H-4-11-ii
225
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.462.229
1.506.096
1.535.341
1.564.585
H-4-11-iii
2.090.851
2.153.577
2.195.394
2.237.211
226
H-4-12-i
1.637.814
1.686.949
1.719.705
1.752.461
227
H-4-12-ii
2.218.527
2.285.082
2.329.453
2.373.823
228
H-4-12-iii
3.701.460
3.812.504
3.886.533
3.960.563
229
I-1-01-i
27.642.940
28.472.229
29.025.087
29.577.946
230
I-1-01-ii
28.251.229
29.098.766
29.663.791
30.228.815
231
I-1-01-iii
44.594.023
45.931.844
46.823.725
47.715.605
232
I-1-02-i
15.336.144
15.796.228
16.102.951
16.409.674
233
I-1-02-ii
19.783.626
20.377.135
20.772.807
21.168.480
234
I-1-02-iii
24.384.469
25.116.003
25.603.693
26.091.382
235
I-1-03-i
9.444.543
9.727.879
9.916.770
10.105.661
236
I-1-03-ii
12.945.372
13.333.733
13.592.641
13.851.548
237
I-1-03-iii
18.986.546
19.556.142
19.935.873
20.315.604
238
I-1-04-i
11.522.066
11.867.728
12.098.169
12.328.610
239
I-1-04-ii
14.800.298
15.244.307
15.540.313
15.836.319
240
I-1-04-iii
31.551.163
32.497.698
33.128.721
33.759.744
241
I-1-05-i
20.297.838
20.906.773
21.312.730
21.718.686
242
I-1-05-ii
24.357.405
25.088.127
25.575.276
26.062.424
243
I-1-05-iii
33.515.636
34.521.105
35.191.418
35.861.731
244
I-1-06-i
9.567.951
9.854.989
10.046.348
10.237.707
245
I-1-06-ii
14.440.308
14.873.518
15.162.324
15.451.130
246
I-1-06-iii
18.589.840
19.147.535
19.519.332
19.891.128
247
I-1-07-i
12.582.579
12.960.057
13.211.708
13.463.360
248
I-1-07-ii
15.523.168
15.988.863
16.299.326
16.609.790
249
I-1-07-iii
16.935.675
17.443.745
17.782.459
18.121.172
250
I-1-11-i
2.393.513
2.465.319
2.513.189
2.561.059
251
I-1-11-ii
2.661.348
2.741.188
2.794.415
2.847.642
252
I-1-11-iii
3.541.442
3.647.686
3.718.515
3.789.343

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
KATETERISASI RINGAN
KATETERISASI SEDANG
KATETERISASI BERAT
RINGAN
SEDANG
BERAT

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
RINGAN
SEDANG
BERAT
- 948 No
Kode
INA-CBG
253
I-1-12-i
254
I-1-12-ii
255
I-1-12-iii
256
I-1-13-i
257
I-1-13-ii
258
I-1-13-iii
259
I-1-14-i
260
I-1-14-ii
261
I-1-14-iii
262
I-1-15-i
263
I-1-15-ii
264
I-1-15-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
7.335.711
7.555.782
7.702.496
7.849.211
10.178.641
10.484.001
10.687.573
10.891.146
14.196.802
14.622.706
14.906.642
15.190.578
4.315.124
4.444.578
4.530.880
4.617.183
5.020.382
5.170.994
5.271.401
5.371.809
9.151.821
9.426.376
9.609.412
9.792.449
15.787.207
16.260.823
16.576.568
16.892.312
19.621.243
20.209.880
20.602.305
20.994.730
25.710.594
26.481.912
26.996.124
27.510.336
3.093.535
3.186.342
3.248.212
3.310.083
9.061.761
9.333.613
9.514.849
9.696.084
46.905.026
48.312.176
49.250.277
50.188.377
6.765.946
6.968.924
7.104.243
7.239.562
17.591.459
18.119.203
18.471.032
18.822.862
20.291.317
20.900.056
21.305.883
21.711.709
2.169.893
2.234.990
2.278.388
2.321.786
4.494.636
4.629.475
4.719.367
4.809.260
26.057.163
26.838.878
27.360.021
27.881.165
2.589.074
2.666.747
2.718.528
2.770.310
4.660.334
4.800.144
4.893.350
4.986.557
6.213.779
6.400.192
6.524.468
6.648.743
7.676.001
7.906.281
8.059.801
8.213.321
15.967.632
16.446.661
16.766.014
17.085.367
24.744.031
25.486.352
25.981.232
26.476.113
10.322.491
10.632.165
10.838.615
11.045.065
14.335.722
14.765.794
15.052.508
15.339.223
17.963.317
18.502.217
18.861.483
19.220.749

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

DARAH VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
265
I-1-16-i
266
I-1-16-ii
267
I-1-16-iii
268
I-1-17-i
269
I-1-17-ii
270
I-1-17-iii
271
I-1-20-i
272
I-1-20-ii
273
I-1-20-iii
274
I-1-30-i
275
I-1-30-ii
276
I-1-30-iii
277
I-1-40-i
278
I-1-40-ii
279
I-1-40-iii
280
I-4-10-i
3.002.080
3.092.143
3.152.184
3.212.226
281
I-4-10-ii
4.740.339
4.882.549
4.977.355
5.072.162
- 949 No
Kode
INA-CBG
282
I-4-10-iii
283
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
6.838.352
7.043.502
7.180.269
7.317.036
I-4-11-i
3.559.682
3.666.473
3.737.666
3.808.860
284
I-4-11-ii
4.405.120
4.537.274
4.625.376
4.713.479
285
I-4-11-iii
7.796.018
8.029.898
8.185.819
8.341.739
286
I-4-12-i
3.117.912
3.211.449
3.273.807
3.336.165
287
I-4-12-ii
4.449.251
4.582.728
4.671.713
4.760.698
288
I-4-12-iii
5.397.567
5.559.494
5.667.446
5.775.397
289
I-4-13-i
2.800.742
2.884.764
2.940.779
2.996.794
290
I-4-13-ii
4.068.906
4.190.973
4.272.351
4.353.729
291
I-4-13-iii
8.328.579
8.578.436
8.745.008
8.911.579
292
I-4-14-i
1.741.803
1.794.057
1.828.893
1.863.729
293
I-4-14-ii
2.038.167
2.099.312
2.140.075
2.180.838
294
I-4-14-iii
3.158.480
3.253.235
3.316.404
3.379.574
2.562.640
2.639.519
2.690.772
2.742.024
3.668.546
3.778.602
3.851.973
3.925.344
4.181.259
4.306.697
4.390.322
4.473.947

VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT

295
I-4-15-i
296
I-4-15-ii
297
I-4-15-iii
298
I-4-16-i
1.921.980
1.979.639
2.018.079
2.056.518
299
I-4-16-ii
3.114.867
3.208.313
3.270.611
3.332.908
300
I-4-16-iii
3.924.179
4.041.905
4.120.388
4.198.872
301
I-4-17-i
HIPERTENSI RINGAN
1.720.132
1.771.736
1.806.139
1.840.541
302
I-4-17-ii
HIPERTENSI SEDANG
2.435.878
2.508.955
2.557.672
2.606.390
303
I-4-17-iii
HIPERTENSI BERAT
2.963.362
3.052.263
3.111.530
3.170.798
2.533.260
2.609.258
2.659.923
2.710.589
3.880.785
3.997.209
4.074.825
4.152.440
5.231.921
5.388.878
5.493.517
5.598.155
1.982.608
2.042.087
2.081.739
2.121.391
3.247.450
3.344.874
3.409.823
3.474.772
3.870.931
3.987.059
4.064.478
4.141.896

RINGAN
SEDANG
KONGENITAL BERAT
RINGAN
SEDANG
BERAT
304
I-4-18-i
305
I-4-18-ii
306
I-4-18-iii
307
I-4-19-i
308
I-4-19-ii
309
I-4-19-iii
310
I-4-20-i
2.406.176
2.478.361
2.526.485
2.574.608
311
I-4-20-ii
2.772.095
2.855.257
2.910.699
2.966.141
312
I-4-20-iii
3.679.031
3.789.402
3.862.982
3.936.563
313
I-4-21-i
3.199.825
3.295.819
3.359.816
3.423.812
314
I-4-21-ii
3.991.574
4.111.321
4.191.152
4.270.984
- 950 No
Kode
INA-CBG
315
I-4-21-iii
316
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.445.353
5.608.714
5.717.621
5.826.528
I-4-22-i
2.082.145
2.144.609
2.186.252
2.227.895
317
I-4-22-ii
2.399.254
2.471.232
2.519.217
2.567.202
318
I-4-22-iii
3.500.446
3.605.460
3.675.469
3.745.478
1.577.342
1.624.662
1.656.209
1.687.756
1.936.613
1.994.711
2.033.443
2.072.175
3.783.964
3.897.483
3.973.163
4.048.842
1.881.314
1.937.753
1.975.379
2.013.006
4.697.120
4.838.033
4.931.976
5.025.918
5.938.659
6.116.819
6.235.592
6.354.365
15.450.441
15.913.954
16.222.963
16.531.972
16.828.984
17.333.853
17.670.433
18.007.013
27.664.717
28.494.658
29.047.953
29.601.247
7.748.042
7.980.484
8.135.445
8.290.405
8.300.218
8.549.224
8.715.229
8.881.233
12.265.357
12.633.318
12.878.625
13.123.932
3.023.398
3.114.100
3.174.568
3.235.036
7.302.605
7.521.684
7.667.736
7.813.788
12.930.160
13.318.065
13.576.668
13.835.271
2.613.183
2.691.579
2.743.843
2.796.106
3.800.669
3.914.689
3.990.702
4.066.716
5.715.032
5.886.483
6.000.784
6.115.085
1.762.214
1.815.080
1.850.325
1.885.569
8.630.248
8.889.156
9.061.761
9.234.365
26.028.449
26.809.303
27.329.872
27.850.441

RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
319
I-4-23-i
320
I-4-23-ii
321
I-4-23-iii
322
I-4-24-i
323
I-4-24-ii
324
I-4-24-iii
325
J-1-01-i
326
J-1-01-ii
327
J-1-01-iii
328
J-1-02-i
329
J-1-02-ii
330
J-1-02-iii
331
J-1-10-i
332
J-1-10-ii
333
J-1-10-iii
334
J-1-20-i
335
J-1-20-ii
336
J-1-20-iii
337
J-1-30-i
338
J-1-30-ii
339
J-1-30-iii
340
J-4-10-i
2.033.830
2.094.845
2.135.522
2.176.198
341
J-4-10-ii
2.908.133
2.995.377
3.053.539
3.111.702
342
J-4-10-iii
4.399.571
4.531.558
4.619.549
4.707.541
343
J-4-11-i
1.283.088
1.321.581
1.347.242
1.372.904
344
J-4-11-ii
1.786.029
1.839.610
1.875.331
1.911.051
345
J-4-11-iii
2.559.426
2.636.208
2.687.397
2.738.585
- 951 No
Kode
INA-CBG
346
J-4-12-i
347
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
EMBOLI PARU RINGAN
1.962.175
2.021.040
2.060.284
2.099.527
J-4-12-ii
EMBOLI PARU SEDANG
2.540.949
2.617.178
2.667.997
2.718.816
348
J-4-12-iii
EMBOLI PARU BERAT
3.393.181
3.494.976
3.562.840
3.630.704
349
J-4-13-i
3.022.494
3.113.169
3.173.619
3.234.069
350
J-4-13-ii
4.443.067
4.576.359
4.665.220
4.754.081
351
J-4-13-iii
7.223.762
7.440.474
7.584.950
7.729.425
352
J-4-14-i
TUMOR PARU RINGAN
2.059.734
2.121.526
2.162.721
2.203.916
353
J-4-14-ii
TUMOR PARU SEDANG
3.450.337
3.553.847
3.622.854
3.691.861
354
J-4-14-iii
TUMOR PARU BERAT
4.102.275
4.225.344
4.307.389
4.389.435
1.921.980
1.979.639
2.018.079
2.056.518
3.478.104
3.582.447
3.652.009
3.721.571
4.345.821
4.476.196
4.563.112
4.650.029
1.601.650
1.649.699
1.681.732
1.713.765
2.242.310
2.309.579
2.354.425
2.399.271
4.044.891
4.166.238
4.247.135
4.328.033

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
355
J-4-15-i
356
J-4-15-ii
357
J-4-15-iii
358
J-4-16-i
359
J-4-16-ii
360
J-4-16-iii
361
J-4-17-i
2.000.213
2.060.219
2.100.224
2.140.228
362
J-4-17-ii
2.702.631
2.783.710
2.837.763
2.891.815
363
J-4-17-iii
3.533.449
3.639.453
3.710.122
3.780.791
364
J-4-18-i
1.799.626
1.853.614
1.889.607
1.925.599
365
J-4-18-ii
2.505.800
2.580.974
2.631.090
2.681.206
366
J-4-18-iii
2.599.068
2.677.040
2.729.021
2.781.003
367
J-4-19-i
2.242.310
2.309.579
2.354.425
2.399.271
368
J-4-19-ii
2.562.640
2.639.519
2.690.772
2.742.024
369
J-4-19-iii
4.014.675
4.135.116
4.215.409
4.295.703
370
J-4-20-i
2.242.310
2.309.579
2.354.425
2.399.271
371
J-4-20-ii
2.735.203
2.817.260
2.871.964
2.926.668
372
J-4-20-iii
6.180.574
6.365.991
6.489.602
6.613.214
1.281.320
1.319.759
1.345.386
1.371.012
3.161.250
3.256.087
3.319.312
3.382.537
4.508.976
4.644.246
4.734.425
4.824.605
3.452.099
3.555.662
3.624.704
3.693.746
4.817.631
4.962.160
5.058.513
5.154.865
5.642.276
5.811.544
5.924.390
6.037.235
373
J-4-21-i
374
J-4-21-ii
375
J-4-21-iii
376
K-1-10-i
377
K-1-10-ii
378
K-1-10-iii

USUS BESAR (RINGAN)
USUS BESAR (SEDANG)
USUS BESAR (BERAT)
- 952 No
Kode
INA-CBG
Deskripsi (INA-CBG)
379
K-1-11-i
380
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.968.274
3.057.323
3.116.688
3.176.054
K-1-11-ii
3.896.986
4.013.896
4.091.835
4.169.775
381
K-1-11-iii
9.889.784
10.186.477
10.384.273
10.582.069
382
K-1-12-i
1.596.704
1.644.606
1.676.540
1.708.474
383
K-1-12-ii
2.081.000
2.143.430
2.185.050
2.226.670
384
K-1-12-iii
4.139.546
4.263.733
4.346.523
4.429.314
385
K-1-13-i
1.813.637
1.868.047
1.904.319
1.940.592
386
K-1-13-ii
3.167.904
3.262.941
3.326.299
3.389.657
387
K-1-13-iii
3.387.959
3.489.597
3.557.357
3.625.116
388
K-1-14-i
2.930.945
3.018.874
3.077.493
3.136.112
389
K-1-14-ii
3.442.727
3.546.009
3.614.864
3.683.718
390
K-1-14-iii
8.476.993
8.731.303
8.900.843
9.070.383
391
K-1-20-i
5.686.894
5.857.501
5.971.238
6.084.976
392
K-1-20-ii
7.937.404
8.175.526
8.334.274
8.493.022
393
K-1-20-iii
16.954.670
17.463.310
17.802.403
18.141.497
394
K-1-30-i
3.743.397
3.855.698
3.930.566
4.005.434
395
K-1-30-ii
6.904.198
7.111.324
7.249.408
7.387.492
396
K-1-30-iii
10.752.403
11.074.975
11.290.024
11.505.072
397
K-1-40-i
3.760.694
3.873.515
3.948.728
4.023.942
398
K-1-40-ii
4.138.270
4.262.418
4.345.183
4.427.949
399
K-1-40-iii
6.862.922
7.068.810
7.206.068
7.343.327
400
K-1-50-i
2.868.502
2.954.557
3.011.927
3.069.297
401
K-1-50-ii
3.714.845
3.826.291
3.900.588
3.974.884
402
K-1-50-iii
PROSEDUR ANAL BERAT
5.274.092
5.432.315
5.537.797
5.643.279
403
K-4-10-i
2.172.684
2.237.864
2.281.318
2.324.772
404
K-4-10-ii
2.599.744
2.677.736
2.729.731
2.781.726
405
K-4-10-iii
10.765.506
11.088.471
11.303.781
11.519.091
406
K-4-11-i
1.281.320
1.319.759
1.345.386
1.371.012
407
K-4-11-ii
1.921.980
1.979.639
2.018.079
2.056.518
408
K-4-11-iii
3.492.930
3.597.718
3.667.576
3.737.435
409
K-4-12-i
1.281.320
1.319.759
1.345.386
1.371.012
410
K-4-12-ii
1.914.272
1.971.700
2.009.986
2.048.271
411
K-4-12-iii
4.594.116
4.731.940
4.823.822
4.915.704


RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
- 953 No
Kode
INA-CBG
412
K-4-13-i
413
K-4-13-ii
414
K-4-13-iii
415
K-4-14-i
416
K-4-14-ii
417
K-4-14-iii
418
K-4-15-i
419
K-4-15-ii
420
K-4-15-iii
421
K-4-16-i
422
K-4-16-ii
423
K-4-16-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.921.980
1.979.639
2.018.079
2.056.518
2.489.437
2.564.120
2.613.909
2.663.698
4.071.630
4.193.778
4.275.211
4.356.644
1.601.650
1.649.699
1.681.732
1.713.765
2.167.666
2.232.696
2.276.049
2.319.402
3.278.801
3.377.165
3.442.741
3.508.317
1.601.650
1.649.699
1.681.732
1.713.765
3.011.538
3.101.885
3.162.115
3.222.346
4.284.877
4.413.423
4.499.121
4.584.819
1.601.650
1.649.699
1.681.732
1.713.765
1.921.980
1.979.639
2.018.079
2.056.518
2.346.026
2.416.407
2.463.327
2.510.248
1.281.320
1.319.759
1.345.386
1.371.012
1.869.470
1.925.554
1.962.943
2.000.332
2.488.073
2.562.715
2.612.477
2.662.238
1.281.320
1.319.759
1.345.386
1.371.012
1.989.140
2.048.814
2.088.597
2.128.380
2.353.143
2.423.737
2.470.800
2.517.862
13.112.068
13.505.430
13.767.671
14.029.913
13.640.165
14.049.370
14.322.173
14.594.977
20.898.308
21.525.257
21.943.223
22.361.189
5.947.248
6.125.665
6.244.610
6.363.555
8.614.608
8.873.046
9.045.338
9.217.630
9.085.723
9.358.295
9.540.010
9.721.724
2.401.326
2.473.365
2.521.392
2.569.418
5.404.663
5.566.803
5.674.897
5.782.990
9.159.476
9.434.261
9.617.450
9.800.640

(RINGAN)
(SEDANG)
RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
424
K-4-17-i
425
K-4-17-ii
426
K-4-17-iii
427
K-4-18-i
428
K-4-18-ii
429
K-4-18-iii
430
L-1-20-i
431
L-1-20-ii
432
L-1-20-iii
433
L-1-30-i
434
L-1-30-ii
435
L-1-30-iii
436
L-1-40-i
437
L-1-40-ii
438
L-1-40-iii
439
L-1-50-i
4.315.124
4.444.578
4.530.880
4.617.183
440
L-1-50-ii
7.767.223
8.000.240
8.155.584
8.310.929
441
L-1-50-iii
9.391.672
9.673.422
9.861.256
10.049.089
442
L-4-10-i
1.921.980
1.979.639
2.018.079
2.056.518
- 954 No
Kode
INA-CBG
443
L-4-10-ii
444
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.242.310
2.309.579
2.354.425
2.399.271
L-4-10-iii
4.536.001
4.672.081
4.762.801
4.853.521
445
L-4-11-i
1.817.843
1.872.378
1.908.735
1.945.092
446
L-4-11-ii
2.490.413
2.565.125
2.614.933
2.664.742
447
L-4-11-iii
6.753.688
6.956.299
7.091.373
7.226.446
448
L-4-12-i
1.921.980
1.979.639
2.018.079
2.056.518
449
L-4-12-ii
2.819.990
2.904.590
2.960.990
3.017.390
450
L-4-12-iii
4.728.790
4.870.654
4.965.229
5.059.805
451
L-4-13-i
1.206.369
1.242.560
1.266.687
1.290.814
452
L-4-13-ii
1.391.014
1.432.745
1.460.565
1.488.385
453
L-4-13-iii
2.086.630
2.149.229
2.190.961
2.232.694
454
L-4-14-i
1.281.320
1.319.759
1.345.386
1.371.012
455
L-4-14-ii
1.921.980
1.979.639
2.018.079
2.056.518
456
L-4-14-iii
3.005.050
3.095.201
3.155.302
3.215.403
457
M-1-01-i
6.246.933
6.434.341
6.559.280
6.684.219
458
M-1-01-ii
6.972.588
7.181.766
7.321.218
7.460.669
459
M-1-01-iii
9.794.597
10.088.435
10.284.327
10.480.219
460
M-1-02-i
4.424.422
4.557.155
4.645.643
4.734.132
461
M-1-02-ii
7.264.060
7.481.982
7.627.263
7.772.544
462
M-1-02-iii
13.154.880
13.549.526
13.812.624
14.075.721
11.219.323
11.555.902
11.780.289
12.004.675
13.129.888
13.523.785
13.786.383
14.048.981
13.376.885
13.778.191
14.045.729
14.313.266
2.918.659
3.006.218
3.064.592
3.122.965
3.741.690
3.853.941
3.928.775
4.003.608
4.682.020
4.822.480
4.916.121
5.009.761
4.546.710
4.683.111
4.774.045
4.864.979
5.254.778
5.412.421
5.517.517
5.622.613
8.950.318
9.218.828
9.397.834
9.576.840
5.018.931
5.169.499
5.269.878
5.370.256
6.723.799
6.925.513
7.059.989
7.194.465
13.697.017
14.107.927
14.381.867
14.655.808
463
M-1-03-i
464
M-1-03-ii
465
M-1-03-iii
466
M-1-04-i
467
M-1-04-ii
468
M-1-04-iii
469
M-1-05-i
470
M-1-05-ii
471
M-1-05-iii
472
M-1-07-i
473
M-1-07-ii
474
M-1-07-iii


- 955 No
Kode
INA-CBG
475
M-1-10-i
476
M-1-10-ii
477
M-1-10-iii
478
M-1-20-i
479
M-1-20-ii
480
M-1-20-iii
481
M-1-30-i
482
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.136.735
3.230.838
3.293.572
3.356.307
11.651.551
12.001.097
12.234.128
12.467.159
14.252.067
14.679.629
14.964.671
15.249.712
3.103.042
3.196.133
3.258.194
3.320.255
4.429.314
4.562.193
4.650.779
4.739.366
8.609.620
8.867.909
9.040.101
9.212.294
1.856.083
1.911.765
1.948.887
1.986.009
M-1-30-ii
3.835.139
3.950.194
4.026.896
4.103.599
483
M-1-30-iii
PROSEDUR KAKI BERAT
5.721.219
5.892.856
6.007.280
6.121.705
484
M-1-40-i
1.875.428
1.931.690
1.969.199
2.006.708
485
M-1-40-ii
3.452.099
3.555.662
3.624.704
3.693.746
486
M-1-40-iii
6.041.174
6.222.409
6.343.232
6.464.056
487
M-1-50-i
2.483.767
2.558.280
2.607.956
2.657.631
488
M-1-50-ii
4.999.882
5.149.879
5.249.876
5.349.874
489
M-1-50-iii
6.904.198
7.111.324
7.249.408
7.387.492
490
M-1-60-i
1.874.461
1.930.694
1.968.184
2.005.673
491
M-1-60-ii
3.752.682
3.865.263
3.940.317
4.015.370
492
M-1-60-iii
6.530.995
6.726.925
6.857.545
6.988.165
493
M-1-70-i
2.511.024
2.586.354
2.636.575
2.686.795
494
M-1-70-ii
5.123.732
5.277.444
5.379.918
5.482.393
495
M-1-70-iii
8.260.074
8.507.877
8.673.078
8.838.280
496
M-1-80-i
2.023.205
2.083.902
2.124.366
2.164.830
497
M-1-80-ii
3.058.673
3.150.433
3.211.607
3.272.780
498
M-1-80-iii
7.041.857
7.253.113
7.393.950
7.534.787
499
M-4-10-i
1.281.320
1.319.759
1.345.386
1.371.012
500
M-4-10-ii
1.954.972
2.013.622
2.052.721
2.091.820
501
M-4-10-iii
FRAKTUR FEMUR BERAT
4.151.280
4.275.819
4.358.844
4.441.870
502
M-4-11-i
1.695.762
1.746.634
1.780.550
1.814.465
503
M-4-11-ii
3.890.330
4.007.040
4.084.846
4.162.653
504
M-4-11-iii
6.905.244
7.112.402
7.250.506
7.388.611
505
M-4-12-i
1.281.320
1.319.759
1.345.386
1.371.012

TULANG WAJAH RINGAN
TULANG WAJAH SEDANG
TULANG WAJAH BERAT
SENDI MAYOR RINGAN
SENDI MAYOR SEDANG
SENDI MAYOR BERAT

RINGAN
SEDANG
BERAT

SELAIN KAKI (BERAT)

PANGGUL RINGAN
PANGGUL SEDANG
PANGGUL BERAT
PELVIS RINGAN
- 956 No
Kode
INA-CBG
506
M-4-12-ii
507
M-4-12-iii
508
M-4-13-i
509
M-4-13-ii
510
M-4-13-iii
511
M-4-14-i
512
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.331.360
2.401.301
2.447.928
2.494.555
4.669.104
4.809.177
4.902.559
4.995.941
2.365.430
2.436.392
2.483.701
2.531.010
3.203.300
3.299.399
3.363.465
3.427.531
7.036.560
7.247.657
7.388.388
7.529.120
2.562.640
2.639.519
2.690.772
2.742.024
M-4-14-ii
3.326.993
3.426.803
3.493.343
3.559.883
513
M-4-14-iii
OSTEOMIELITIS BERAT
4.983.478
5.132.982
5.232.651
5.332.321
514
M-4-15-i
1.598.813
1.646.777
1.678.754
1.710.730
515
M-4-15-ii
2.131.885
2.195.842
2.238.480
2.281.117
516
M-4-15-iii
5.445.609
5.608.978
5.717.890
5.826.802
517
M-4-16-i
1.601.650
1.649.699
1.681.732
1.713.765
518
M-4-16-ii
2.562.640
2.639.519
2.690.772
2.742.024
519
M-4-16-iii
4.765.045
4.907.997
5.003.298
5.098.598
520
M-4-17-i
1.601.650
1.649.699
1.681.732
1.713.765
521
M-4-17-ii
2.242.310
2.309.579
2.354.425
2.399.271
522
M-4-17-iii
3.131.505
3.225.450
3.288.080
3.350.710
523
M-4-18-i
1.877.382
1.933.704
1.971.251
2.008.799
524
M-4-18-ii
2.562.640
2.639.519
2.690.772
2.742.024
525
M-4-18-iii
3.183.931
3.279.449
3.343.127
3.406.806
526
M-4-19-i
1.395.859
1.437.735
1.465.652
1.493.569
527
M-4-19-ii
2.351.074
2.421.606
2.468.628
2.515.649
528
M-4-19-iii
4.591.821
4.729.576
4.821.412
4.913.249
529
M-4-20-i
1.281.320
1.319.759
1.345.386
1.371.012
530
M-4-20-ii
1.921.980
1.979.639
2.018.079
2.056.518
531
M-4-20-iii
2.130.007
2.193.907
2.236.507
2.279.107
532
M-4-21-i
1.281.320
1.319.759
1.345.386
1.371.012
533
M-4-21-ii
1.672.445
1.722.618
1.756.067
1.789.516
534
M-4-21-iii
4.076.714
4.199.016
4.280.550
4.362.084
535
N-1-01-i
3.466.905
3.570.912
3.640.250
3.709.588
536
N-1-01-ii
4.688.911
4.829.578
4.923.356
5.017.134

PELVIS SEDANG
PELVIS BERAT

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
RINGAN
SEDANG
BERAT
ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
- 957 No
Kode
INA-CBG
537
N-1-01-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
9.941.885
10.240.142
10.438.980
10.637.817
4.782.863
4.926.349
5.022.006
5.117.663
6.468.714
6.662.776
6.792.150
6.921.524
13.715.598
14.127.066
14.401.378
14.675.690
2.589.074
2.666.747
2.718.528
2.770.310
6.023.298
6.203.997
6.324.463
6.444.929
10.977.837
11.307.172
11.526.728
11.746.285
538
N-1-11-i
539
N-1-11-ii
540
N-1-11-iii
541
N-1-12-i
542
N-1-12-ii
543
N-1-12-iii
544
N-1-20-i
3.505.402
3.610.564
3.680.672
3.750.780
545
N-1-20-ii
6.949.967
7.158.466
7.297.465
7.436.464
546
N-1-20-iii
7.950.132
8.188.636
8.347.638
8.506.641
4.170.295
4.295.404
4.378.809
4.462.215
6.337.283
6.527.401
6.654.147
6.780.893
7.295.258
7.514.115
7.660.021
7.805.926
3.757.844
3.870.579
3.945.736
4.020.893
5.093.891
5.246.708
5.348.586
5.450.464
5.924.343
6.102.073
6.220.560
6.339.047
1.601.650
1.649.699
1.681.732
1.713.765
2.144.654
2.208.993
2.251.887
2.294.780
4.694.261
4.835.089
4.928.974
5.022.859


URIN BAWAH RINGAN
URIN BAWAH SEDANG
URIN BAWAH BERAT
RINGAN
SEDANG
BERAT
GINJAL RINGAN
GINJAL SEDANG
GINJAL BERAT
547
N-1-30-i
548
N-1-30-ii
549
N-1-30-iii
550
N-1-40-i
551
N-1-40-ii
552
N-1-40-iii
553
N-4-10-i
554
N-4-10-ii
555
N-4-10-iii
556
N-4-11-i
1.226.548
1.263.345
1.287.876
1.312.407
557
N-4-11-ii
2.072.837
2.135.022
2.176.479
2.217.936
558
N-4-11-iii
2.402.475
2.474.549
2.522.598
2.570.648
559
N-4-12-i
1.281.320
1.319.759
1.345.386
1.371.012
560
N-4-12-ii
1.921.980
1.979.639
2.018.079
2.056.518
561
N-4-12-iii
3.191.118
3.286.852
3.350.674
3.414.496
562
N-4-13-i
BATU URIN RINGAN
1.690.455
1.741.168
1.774.977
1.808.787
563
N-4-13-ii
BATU URIN SEDANG
2.038.053
2.099.194
2.139.955
2.180.716
564
N-4-13-iii
BATU URIN BERAT
5.019.165
5.169.740
5.270.123
5.370.506
565
N-4-14-i
1.109.860
1.143.156
1.165.353
1.187.551
566
N-4-14-ii
1.709.045
1.760.317
1.794.498
1.828.679
567
N-4-14-iii
2.771.527
2.854.673
2.910.103
2.965.534

(RINGAN)
(SEDANG)
- 958 No
Kode
INA-CBG
Deskripsi (INA-CBG)
(BERAT)
SALURAN URIN RINGAN
SALURAN URIN SEDANG
SALURAN URIN BERAT
RINGAN
SEDANG
BERAT
&KURET RINGAN
KURET SEDANG
KURET BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.646.565
1.695.961
1.728.893
1.761.824
2.259.599
2.327.387
2.372.579
2.417.771
2.578.610
2.655.968
2.707.541
2.759.113
2.137.013
2.201.124
2.243.864
2.286.604
2.562.640
2.639.519
2.690.772
2.742.024
5.388.850
5.550.515
5.658.292
5.766.069
3.155.406
3.250.068
3.313.176
3.376.284
3.502.981
3.608.071
3.678.130
3.748.190
3.926.884
4.044.690
4.123.228
4.201.766
1.649.128
1.698.602
1.731.584
1.764.567
2.115.680
2.179.151
2.221.464
2.263.778
3.585.422
3.692.984
3.764.693
3.836.401
1.436.068
1.479.150
1.507.872
1.536.593
1.724.714
1.776.456
1.810.950
1.845.444
2.166.856
2.231.862
2.275.199
2.318.536
568
N-4-15-i
569
N-4-15-ii
570
N-4-15-iii
571
N-4-16-i
572
N-4-16-ii
573
N-4-16-iii
574
O-6-10-i
575
O-6-10-ii
576
O-6-10-iii
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
1.439.199
1.482.375
1.511.159
1.539.943
584
O-6-13-ii
2.121.097
2.184.730
2.227.152
2.269.574
585
O-6-13-iii
2.506.809
2.582.014
2.632.150
2.682.286
586
P-8-01-i
32.194.235
33.160.062
33.803.947
34.447.832
587
P-8-01-ii
39.835.330
41.030.390
41.827.097
42.623.803
588
P-8-01-iii
46.755.511
48.158.176
49.093.286
50.028.397
589
P-8-02-i
39.005.829
40.176.004
40.956.120
41.736.237
590
P-8-02-ii
44.743.701
46.086.012
46.980.886
47.875.760
591
P-8-02-iii
51.122.877
52.656.563
53.679.021
54.701.479
592
P-8-03-i
2.157.562
2.222.289
2.265.440
2.308.591
593
P-8-03-ii
3.020.587
3.111.204
3.171.616
3.232.028
594
P-8-03-iii
4.758.109
4.900.853
4.996.015
5.091.177

- 959 No
Kode
INA-CBG
595
P-8-04-i
596
P-8-04-ii
597
P-8-04-iii
598
P-8-05-i
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii
603
P-8-06-iii
604
P-8-07-i
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
614
P-8-11-ii
615
P-8-11-iii
616
P-8-12-i
617
P-8-12-ii
618
P-8-12-iii
619
P-8-13-i
620
P-8-13-ii
621
P-8-13-iii
622
P-8-14-i
Deskripsi (INA-CBG)
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
RINGAN
SEDANG
BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
19.268.544
19.846.601
20.231.972
20.617.342
25.006.416
25.756.609
26.256.737
26.756.865
35.852.906
36.928.494
37.645.552
38.362.610
10.477.610
10.791.938
11.001.490
11.211.042
14.850.599
15.296.117
15.593.129
15.890.141
21.880.364
22.536.775
22.974.382
23.411.990
1.726.050
1.777.831
1.812.352
1.846.873
4.343.193
4.473.489
4.560.353
4.647.217
8.078.835
8.321.200
8.482.776
8.644.353
3.020.587
3.111.204
3.171.616
3.232.028
8.468.998
8.723.068
8.892.448
9.061.828
11.219.323
11.555.902
11.780.289
12.004.675
2.188.964
2.254.633
2.298.413
2.342.192
3.107.543
3.200.769
3.262.920
3.325.071
4.386.896
4.518.503
4.606.241
4.693.979
1.358.031
1.398.772
1.425.932
1.453.093
1.967.305
2.026.325
2.065.671
2.105.017
3.862.400
3.978.272
4.055.520
4.132.768
3.824.792
3.939.536
4.016.032
4.092.528
8.142.878
8.387.164
8.550.022
8.712.879
8.313.472
8.562.877
8.729.146
8.895.416
1.804.437
1.858.570
1.894.658
1.930.747
2.805.586
2.889.753
2.945.865
3.001.977
3.309.998
3.409.298
3.475.498
3.541.697
932.630
960.609
979.262
997.914
1.725.825
1.777.599
1.812.116
1.846.632
2.581.155
2.658.590
2.710.213
2.761.836
1.704.012
1.755.133
1.789.213
1.823.293
- 960 No
Kode
INA-CBG
623
P-8-14-ii
624
P-8-14-iii
625
P-8-15-i
626
P-8-15-ii
627
P-8-15-iii
628
P-8-16-i
629
P-8-16-ii
630
P-8-16-iii
631
P-8-17-i
632
P-8-17-ii
633
P-8-17-iii
634
S-4-10-i
635
S-4-10-ii
636
S-4-10-iii
637
S-4-11-i
638
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.479.111
3.583.484
3.653.066
3.722.648
3.816.571
3.931.069
4.007.400
4.083.731
1.281.470
1.319.914
1.345.544
1.371.173
2.561.322
2.638.162
2.689.388
2.740.615
3.008.669
3.098.930
3.159.103
3.219.276
1.160.034
1.194.835
1.218.035
1.241.236
1.645.557
1.694.924
1.727.835
1.760.746
2.136.014
2.200.094
2.242.815
2.285.535
765.620
788.588
803.901
819.213
2.543.129
2.619.423
2.670.286
2.721.148
5.133.144
5.287.139
5.389.802
5.492.464
1.281.320
1.319.759
1.345.386
1.371.012
1.601.650
1.649.699
1.681.732
1.713.765
2.081.870
2.144.326
2.185.963
2.227.601
800.825
824.850
840.866
856.883
S-4-11-ii
1.218.871
1.255.437
1.279.814
1.304.192
639
S-4-11-iii
1.971.919
2.031.077
2.070.515
2.109.954
640
S-4-12-i
960.990
989.820
1.009.039
1.028.259
641
S-4-12-ii
1.281.320
1.319.759
1.345.386
1.371.012
642
S-4-12-iii
2.502.519
2.577.595
2.627.645
2.677.695
643
S-4-13-i
1.281.320
1.319.759
1.345.386
1.371.012
644
S-4-13-ii
2.265.086
2.333.039
2.378.340
2.423.642
645
S-4-13-iii
4.612.003
4.750.363
4.842.604
4.934.844
646
S-4-14-i
780.685
804.105
819.719
835.333
647
S-4-14-ii
1.658.436
1.708.189
1.741.358
1.774.526
648
S-4-14-iii
3.144.986
3.239.335
3.302.235
3.365.135
649
S-4-15-i
590.439
608.152
619.961
631.770
650
S-4-15-ii
1.114.359
1.147.790
1.170.077
1.192.365
651
S-4-15-iii
1.443.354
1.486.655
1.515.522
1.544.389
652
S-4-16-i
LUKA BAKAR RINGAN
2.242.310
2.309.579
2.354.425
2.399.271
653
S-4-16-ii
LUKA BAKAR SEDANG
3.166.872
3.261.878
3.325.215
3.388.553
654
S-4-16-iii
LUKA BAKAR BERAT
5.654.941
5.824.589
5.937.688
6.050.787

ASPIRASI RINGAN
ASPIRASI SEDANG
ASPIRASI BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT

PASIEN RINGAN
PASIEN SEDANG
PASIEN BERAT
- 961 No
Kode
INA-CBG
655
S-4-17-i
656
S-4-17-ii
657
S-4-17-iii
658
T-1-10-i
659
T-1-10-ii
660
T-1-10-iii
661
T-4-10-i
662
T-4-10-ii
663
T-4-10-iii
664
T-4-11-i
665
T-4-11-ii
666
T-4-11-iii
667
T-4-12-i
668
T-4-12-ii
669
T-4-12-iii
670
U-1-10-i
671
U-1-10-ii
672
U-1-10-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.195.643
1.231.513
1.255.426
1.279.339
1.601.650
1.649.699
1.681.732
1.713.765
2.611.806
2.690.160
2.742.396
2.794.632
1.234.234
1.271.261
1.295.946
1.320.630
1.657.493
1.707.217
1.740.367
1.773.517
3.015.519
3.105.985
3.166.295
3.226.606
539.889
556.086
566.884
577.681
1.028.909
1.059.776
1.080.355
1.100.933
1.495.755
1.540.627
1.570.542
1.600.457
533.919
549.937
560.615
571.294
840.237
865.444
882.249
899.054
1.353.375
1.393.976
1.421.044
1.448.111
1.121.155
1.154.790
1.177.213
1.199.636
1.694.564
1.745.401
1.779.292
1.813.183
2.636.132
2.715.216
2.767.939
2.820.662
1.193.367
1.229.168
1.253.035
1.276.902
2.435.138
2.508.192
2.556.895
2.605.598
10.515.418
10.830.880
11.041.188
11.251.497
5.178.149
5.333.493
5.437.056
5.540.619
6.904.198
7.111.324
7.249.408
7.387.492
11.599.668
11.947.658
12.179.651
12.411.645

DOKTER RINGAN
DOKTER SEDANG
DOKTER BERAT

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
673
U-1-11-i
674
U-1-11-ii
675
U-1-11-iii
676
U-1-12-i
3.164.423
3.259.355
3.322.644
3.385.932
677
U-1-12-ii
7.767.223
8.000.240
8.155.584
8.310.929
678
U-1-12-iii
10.085.886
10.388.463
10.590.181
10.791.899
679
U-1-13-i
3.452.099
3.555.662
3.624.704
3.693.746
680
U-1-13-ii
3.894.905
4.011.752
4.089.650
4.167.548
681
U-1-13-iii
7.510.474
7.735.789
7.885.998
8.036.208
1.904.760
1.961.903
1.999.998
2.038.093
2.337.523
2.407.649
2.454.400
2.501.150
2.770.031
2.853.132
2.908.532
2.963.933
1.118.738
1.152.300
1.174.675
1.197.050
682
U-1-14-i
683
U-1-14-ii
684
U-1-14-iii
685
U-1-15-i

- 962 No
Kode
INA-CBG
686
U-1-15-ii
687
U-1-15-iii
688
U-1-20-i
689
U-1-20-ii
690
U-1-20-iii
691
U-1-30-i
692
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.589.649
1.637.338
1.669.131
1.700.924
3.132.467
3.226.441
3.289.090
3.351.739
2.893.688
2.980.499
3.038.373
3.096.246
5.150.765
5.305.288
5.408.303
5.511.318
12.707.125
13.088.339
13.342.481
13.596.624
2.482.280
2.556.748
2.606.394
2.656.039
U-1-30-ii
3.351.078
3.451.610
3.518.632
3.585.653
693
U-1-30-iii
6.569.076
6.766.148
6.897.530
7.028.911
694
U-4-10-i
2.310.588
2.379.905
2.426.117
2.472.329
695
U-4-10-ii
5.792.158
5.965.923
6.081.766
6.197.610
696
U-4-10-iii
8.449.498
8.702.983
8.871.973
9.040.963
697
U-4-11-i
1.281.320
1.319.759
1.345.386
1.371.012
698
U-4-11-ii
1.921.980
1.979.639
2.018.079
2.056.518
699
U-4-11-iii
2.658.090
2.737.833
2.790.995
2.844.157
700
U-4-12-i
1.281.320
1.319.759
1.345.386
1.371.012
701
U-4-12-ii
1.493.724
1.538.536
1.568.410
1.598.284
702
U-4-12-iii
2.374.953
2.446.202
2.493.701
2.541.200
703
U-4-13-i
1.258.802
1.296.566
1.321.742
1.346.918
704
U-4-13-ii
1.463.431
1.507.334
1.536.603
1.565.871
705
U-4-13-iii
1.661.619
1.711.468
1.744.700
1.777.932
706
U-4-14-i
1.601.650
1.649.699
1.681.732
1.713.765
707
U-4-14-ii
1.921.980
1.979.639
2.018.079
2.056.518
708
U-4-14-iii
3.219.650
3.316.239
3.380.632
3.445.025
1.281.320
1.319.759
1.345.386
1.371.012
1.601.650
1.649.699
1.681.732
1.713.765
2.242.744
2.310.027
2.354.882
2.399.736
3.745.723
3.858.094
3.933.009
4.007.923
4.315.124
4.444.578
4.530.880
4.617.183
8.198.736
8.444.698
8.608.672
8.772.647


DAN TELINGA RINGAN
DAN TELINGA SEDANG
DAN TELINGA BERAT


KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT
709
U-4-15-i
710
U-4-15-ii
711
U-4-15-iii
712
V-1-10-i
713
V-1-10-ii
714
V-1-10-iii
715
V-1-11-i
4.315.124
4.444.578
4.530.880
4.617.183
716
V-1-11-ii
4.815.751
4.960.223
5.056.538
5.152.853
717
V-1-11-iii
7.131.390
7.345.331
7.487.959
7.630.587
718
V-1-12-i

2.330.514
2.400.429
2.447.040
2.493.650
- 963 No
Kode
INA-CBG
719
V-1-12-ii
720
V-1-12-iii
721
V-1-13-i
722
V-1-13-ii
723
V-1-13-iii
724
V-1-14-i
725
V-1-14-ii
726
V-1-14-iii
727
V-1-15-i
728
V-1-15-ii
729
V-1-15-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
8.906.450
9.173.643
9.351.772
9.529.901
10.399.092
10.711.065
10.919.046
11.127.028
3.532.304
3.638.273
3.708.919
3.779.565
6.712.391
6.913.763
7.048.010
7.182.258
10.356.298
10.666.987
10.874.113
11.081.239
4.258.233
4.385.980
4.471.145
4.556.310
6.193.235
6.379.033
6.502.897
6.626.762
8.418.803
8.671.367
8.839.743
9.008.119
2.007.520
2.067.746
2.107.896
2.148.046
3.823.935
3.938.653
4.015.131
4.091.610
6.722.404
6.924.076
7.058.524
7.192.972
3.232.614
3.329.592
3.394.245
3.458.897
4.175.307
4.300.566
4.384.072
4.467.578
7.979.744
8.219.137
8.378.732
8.538.326
1.643.905
1.693.222
1.726.100
1.758.979
2.402.008
2.474.068
2.522.109
2.570.149
3.963.154
4.082.049
4.161.312
4.240.575
4.833.886
4.978.903
5.075.581
5.172.258
5.822.187
5.996.852
6.113.296
6.229.740
12.860.054
13.245.856
13.503.057
13.760.258

NON KOMPLEK (BERAT)

RINGAN
SEDANG
BERAT
730
V-4-10-i
731
V-4-10-ii
732
V-4-10-iii
733
V-4-11-i
734
V-4-11-ii
735
V-4-11-iii
736
W-1-01-i
737
W-1-01-ii
738
W-1-01-iii
739
W-1-10-i
1.346.232
1.386.618
1.413.543
1.440.468
740
W-1-10-ii
2.512.289
2.587.658
2.637.903
2.688.149
741
W-1-10-iii
4.109.308
4.232.587
4.314.773
4.396.959
742
W-1-11-i
1.398.287
1.440.235
1.468.201
1.496.167
743
W-1-11-ii
2.696.773
2.777.676
2.831.612
2.885.547
744
W-1-11-iii
5.178.149
5.333.493
5.437.056
5.540.619
745
W-1-12-i
1.270.554
1.308.670
1.334.081
1.359.493
746
W-1-12-ii
1.444.595
1.487.933
1.516.825
1.545.717
747
W-1-12-iii
2.219.080
2.285.653
2.330.035
2.374.416
748
W-1-13-i
1.512.259
1.557.627
1.587.872
1.618.117
749
W-1-13-ii
1.641.878
1.691.134
1.723.972
1.756.809
750
W-1-13-iii
2.205.345
2.271.505
2.315.612
2.359.719

SERVIK RINGAN
SERVIK SEDANG
SERVIK BERAT
ENDOSKOP RINGAN
ENDOSKOP SEDANG
ENDOSKOP BERAT
- 964 No
Kode
INA-CBG
751
W-1-20-i
752
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.120.476
4.244.090
4.326.499
4.408.909
W-1-20-ii
5.796.067
5.969.949
6.085.871
6.201.792
753
W-1-20-iii
7.322.067
7.541.729
7.688.170
7.834.611
754
W-1-30-i
2.249.367
2.316.848
2.361.835
2.406.822
755
W-1-30-ii
3.587.856
3.695.492
3.767.249
3.839.006
756
W-1-30-iii
9.540.992
9.827.222
10.018.042
10.208.861
757
W-4-10-i
1.677.464
1.727.788
1.761.337
1.794.886
758
W-4-10-ii
2.267.280
2.335.299
2.380.644
2.425.990
759
W-4-10-iii
5.125.279
5.279.038
5.381.543
5.484.049
760
W-4-11-i
1.601.650
1.649.699
1.681.732
1.713.765
761
W-4-11-ii
2.562.640
2.639.519
2.690.772
2.742.024
762
W-4-11-iii
3.114.367
3.207.798
3.270.085
3.332.372
763
W-4-12-i
1.281.320
1.319.759
1.345.386
1.371.012
764
W-4-12-ii
1.761.815
1.814.669
1.849.906
1.885.142
765
W-4-12-iii
1.964.228
2.023.155
2.062.439
2.101.724
766
W-4-13-i
ABORTUS RINGAN
702.691
723.772
737.825
751.879
767
W-4-13-ii
ABORTUS SEDANG
960.990
989.820
1.009.039
1.028.259
768
W-4-13-iii
ABORTUS BERAT
1.281.320
1.319.759
1.345.386
1.371.012
769
W-4-14-i
960.990
989.820
1.009.039
1.028.259
770
W-4-14-ii
1.235.988
1.273.068
1.297.788
1.322.507
771
W-4-14-iii
1.555.251
1.601.909
1.633.014
1.664.119
772
W-4-15-i
801.354
825.394
841.421
857.448
773
W-4-15-ii
891.258
917.996
935.821
953.646
774
W-4-15-iii
1.234.031
1.271.052
1.295.733
1.320.414
775
W-4-16-i
960.990
989.820
1.009.039
1.028.259
776
W-4-16-ii
1.281.320
1.319.759
1.345.386
1.371.012
777
W-4-16-iii
1.746.905
1.799.312
1.834.251
1.869.189
778
W-4-17-i
784.894
808.441
824.139
839.837
779
W-4-17-ii
1.281.320
1.319.759
1.345.386
1.371.012
780
W-4-17-iii
2.424.002
2.496.722
2.545.202
2.593.682
781
Z-4-10-i
REHABILITASI RINGAN
2.198.593
2.264.551
2.308.523
2.352.495
782
Z-4-10-ii
REHABILITASI SEDANG
2.918.315
3.005.864
3.064.231
3.122.597
783
Z-4-10-iii
REHABILITASI BERAT
4.145.745
4.270.117
4.353.032
4.435.947
784
Z-4-11-i
1.919.130
1.976.704
2.015.086
2.053.469
785
Z-4-11-ii
2.310.208
2.379.514
2.425.719
2.471.923

RINGAN
SEDANG
BERAT

- 965 No
Kode
INA-CBG
786
Z-4-11-iii
787
Z-4-12-i
788
Z-4-12-ii
789
Z-4-12-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.655.160
3.764.815
3.837.918
3.911.021
960.990
989.820
1.009.039
1.028.259
1.957.985
2.016.725
2.055.884
2.095.044
2.488.289
2.562.938
2.612.704
2.662.469
- 966 b. RawatJalan
No
Kode
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
749.845
772.341
787.338
802.335
972.667
1.001.847
1.021.300
1.040.753
1.808.802
1.863.066
1.899.242
1.935.418
1.494.799
1.539.643
1.569.539
1.599.435
1.248.776
1.286.239
1.311.215
1.336.190
437.826
450.961
459.718
468.474
976.295
1.005.584
1.025.110
1.044.636
B-3-12-0

200.597
206.615
210.627
214.638
C-3-10-0
547.199
563.615
574.559
585.503
10
C-3-11-0

KANDUNG KEMIH
865.416
891.379
908.687
925.995
11
C-3-12-0
196.188
202.074
205.997
209.921
190.512
196.227
200.038
203.848
1.621.832
1.670.487
1.702.924
1.735.360
1.486.474
1.531.068
1.560.797
1.590.527

LAPAROSKOPI
PANKREAS
LAPAROSKOPI
EMPEDU

OVARIUM
GASTROINTESTINAL
GINJAL ATAU PROSTAT
12
C-3-13-0
13
C-3-14-0
14
C-3-15-0
15
C-3-16-0
337.096
347.209
353.951
360.693
16
C-3-17-0

LEHER
223.620
230.328
234.801
239.273
17
C-3-18-0
99.143
102.118
104.101
106.083
18
C-3-19-0

MYELOMA ATAU TESTIS
140.209
144.415
147.219
150.024
19
C-3-20-0
2.792.265
2.876.033
2.931.878
2.987.724
20
C-3-21-0
160.003
164.804
168.004
171.204
21
C-3-22-0
702.500
723.575
737.625
751.675
22
C-3-23-0
113.790
117.203
119.479
121.755
23
D-2-10-0

TULANG
964.042
992.964
1.012.244
1.031.525
24
D-2-11-0
1.207.146
1.243.360
1.267.503
1.291.646
1.012.453
1.042.827
1.063.076
1.083.325
222.203
228.869
233.313
237.757
160.947
165.776
168.995
172.213
417.865
430.401
438.758
447.116
247.874
255.311
260.268
265.226
179.700
185.092
188.686
192.280
179.700
185.092
188.686
192.280
25
D-2-21-0
26
D-2-22-0
27
D-3-10-0
28
D-3-11-0
29
E-2-10-0
30
E-2-21-0
31
E-2-22-0
PROSEDUR LIMPA
TYMUS
TYMUS
TULANG
PEMBENTUK DARAH
PARATIROID
THYROGLOSSAL
- 967 No
Kode
INA-CBG
32
E-3-10-0
33
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

ENDOKRIN
208.980
215.249
219.429
223.609
F-3-10-0
TERAPI SHOCK
291.520
300.266
306.096
311.927
34
F-5-10-0
357.207
367.923
375.067
382.211
35
F-5-11-0
TERAPI KELOMPOK
235.545
242.611
247.322
252.033
36
F-5-12-0
301.420
310.463
316.491
322.519
37
F-5-13-0
255.283
262.941
268.047
273.152
38
F-5-14-0
171.261
176.398
179.824
183.249
39
F-5-15-0
160.664
165.484
168.698
171.911
40
F-5-16-0
167.347
172.368
175.715
179.062
41
G-2-10-0
140.919
145.147
147.965
150.784
42
G-2-11-0
1.221.549
1.258.195
1.282.626
1.307.057
43
G-2-12-0

EKSTRAKRANIAL
1.770.325
1.823.434
1.858.841
1.894.247
44
G-2-13-0
434.300
447.329
456.015
464.701
45
G-2-21-0
792.090
815.853
831.695
847.537
46
G-2-22-0
718.889
740.456
754.834
769.211
47
G-2-31-0
1.186.230
1.221.817
1.245.541
1.269.266
48
G-2-32-0
608.060
626.302
638.463
650.625
49
G-3-10-0
241.343
248.583
253.410
258.237
50
G-3-11-0
321.423
331.065
337.494
343.922
51
G-3-12-0
526.657
542.456
552.989
563.522
52
G-3-13-0
526.717
542.518
553.052
563.587
53
H-2-21-0
691.237
711.974
725.799
739.624
54
H-2-22-0
179.700
185.092
188.686
192.280
55
H-2-23-0
179.700
185.092
188.686
192.280
56
H-2-31-0
1.144.977
1.179.326
1.202.226
1.225.126
57
H-2-32-0
119.165
122.740
125.124
127.507
58
H-2-33-0
179.700
185.092
188.686
192.280
59
H-2-34-0
513.665
529.075
539.348
549.621
60
H-2-35-0
169.264
174.342
177.727
181.113
61
H-2-36-0
913.648
941.058
959.331
977.604
62
H-2-37-0

972.619
1.001.797
1.021.250
1.040.702
63
H-3-10-0
338.400
348.552
355.320
362.088
64
H-3-11-0
177.961
183.300
186.859
190.418

AKUT
MENTAL
PROSEDUR KRANIOTOMI

MATA
MATA
MATA
MATA
MATA
- 968 No
Kode
INA-CBG
65
H-3-12-0
66
H-3-13-0
67
I-2-11-0
68
I-2-12-0
69
I-2-13-0
70
I-2-14-0
71
I-2-15-0
Deskripsi (INA-CBG)
MATA
TORASIK
ABDOMEN
PENGGANTIAN ALAT
DARAH VENA
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
185.800
191.374
195.090
198.806
180.401
185.813
189.421
193.029
2.080.408
2.142.820
2.184.428
2.226.036
1.462.754
1.506.636
1.535.891
1.565.147
1.859.072
1.914.844
1.952.026
1.989.207
3.290.162
3.388.866
3.454.670
3.520.473
197.864
203.800
207.757
211.714
2.078.153
2.140.498
2.182.061
2.223.624
685.107
705.661
719.363
733.065
72
I-2-16-0
73
I-2-17-0
74
I-2-21-0
1.604.039
1.652.160
1.684.241
1.716.322
75
I-2-22-0
1.510.484
1.555.798
1.586.008
1.616.217
76
I-2-23-0
309.116
318.389
324.572
330.754
77
I-2-31-0
2.404.099
2.476.222
2.524.304
2.572.386
78
I-2-32-0
3.143.712
3.238.024
3.300.898
3.363.772
79
I-2-41-0
2.107.898
2.171.135
2.213.293
2.255.451
80
I-2-42-0

LAIN
2.450.780
2.524.303
2.573.319
2.622.335
81
I-3-10-0
PROSEDUR RESUSITASI
311.105
320.438
326.660
332.882
82
I-3-11-0
164.200
169.126
172.410
175.694
83
I-3-12-0
954.271
982.899
1.001.984
1.021.070
84
I-3-13-0
313.419
322.822
329.090
335.359
85
I-3-14-0
200.891
206.918
210.936
214.954
177.961
183.300
186.859
190.418
1.101.820
1.134.875
1.156.911
1.178.948
177.613
182.942
186.494
190.046
895.060
921.912
939.813
957.714
1.160.973
1.195.802
1.219.021
1.242.241

PACU JANTUNG

KARDIOVASKULAR
PERNAFASAN
PENDEK
86
I-3-15-0
87
J-2-10-0
88
J-2-21-0
89
J-2-22-0
90
J-2-31-0
PROSEDUR
91
J-2-32-0
863.956
889.875
907.154
924.433
92
J-3-10-0
179.700
185.092
188.686
192.280
93
J-3-11-0

PADA DADA
507.802
523.036
533.192
543.348
94
J-3-12-0
196.188
202.074
205.997
209.921
95
J-3-13-0
288.740
297.402
303.177
308.952
96
J-3-14-0
306.529
315.725
321.855
327.986
- 969 No
Kode
INA-CBG
97
J-3-15-0
98
J-3-16-0
99
J-3-17-0
100
K-2-10-0
101
K-2-11-0
102
K-2-12-0

103
K-2-13-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
268.801
276.865
282.241
287.617
306.529
315.725
321.855
327.986
179.700
185.092
188.686
192.280
517.240
532.757
543.102
553.446
1.104.517
1.137.653
1.159.743
1.181.834
847.860
873.295
890.253
907.210
1.379.937
1.421.336
1.448.934
1.476.533
179.700
185.092
188.686
192.280
179.700
185.092
188.686
192.280
2.309.579
2.378.867
2.425.058
2.471.250
776.594
799.892
815.424
830.956
179.700
185.092
188.686
192.280

PERNAFASAN
KECIL

FEMORALIS
USUS BESAR
ATAS
ATAS
104
K-2-14-0
105
K-2-21-0
106
K-2-22-0
107
K-2-31-0
108
K-2-32-0
109
K-2-41-0
855.435
881.098
898.206
915.315
110
K-2-42-0

244.408
251.740
256.629
261.517
111
K-2-51-0
566.863
583.869
595.206
606.543
112
K-2-52-0
309.116
318.389
324.572
330.754
113
K-2-53-0
179.700
185.092
188.686
192.280
114
K-3-10-0

GASTROINTESTINAL
341.958
352.217
359.056
365.895
115
K-3-11-0
205.584
211.751
215.863
219.974
116
K-3-12-0
208.488
214.742
218.912
223.082
117
K-3-13-0
179.700
185.092
188.686
192.280
481.601
496.049
505.681
515.313
232.572
239.549
244.201
248.852
308.173
317.418
323.581
329.745
1.059.509
1.091.294
1.112.484
1.133.674
679.138
699.512
713.095
726.677
306.529
315.725
321.855
327.986
309.116
318.389
324.572
330.754

GASTROINTESTINAL
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
118
K-3-14-0
119
K-3-15-0
120
K-3-16-0
121
L-2-21-0
122
L-2-22-0
123
L-2-31-0
124
L-2-32-0
125
L-2-41-0
925.611
953.379
971.892
990.404
126
L-2-42-0

207.600
213.828
217.980
222.132
127
L-2-51-0
1.385.785
1.427.358
1.455.074
1.482.790
L-2-52-0

1.060.171
1.091.976
1.113.180
1.134.383
128
- 970 No
Kode
INA-CBG
129
L-2-53-0
130
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

179.700
185.092
188.686
192.280
L-3-10-0
244.408
251.740
256.629
261.517
131
L-3-11-0
237.337
244.457
249.204
253.951
132
L-3-12-0
180.755
186.178
189.793
193.408
133
M-2-10-0
1.417.759
1.460.291
1.488.647
1.517.002
134
M-2-21-0
1.269.701
1.307.792
1.333.186
1.358.580
135
M-2-22-0
309.116
318.389
324.572
330.754
136
M-2-31-0
PROSEDUR BUNION
771.216
794.352
809.777
825.201
137
M-2-32-0
244.408
251.740
256.629
261.517
138
M-2-41-0

TULANG
244.408
251.740
256.629
261.517
139
M-2-42-0
84.230
86.757
88.441
90.126
140
M-2-51-0
179.700
185.092
188.686
192.280
141
M-2-52-0
179.700
185.092
188.686
192.280
142
M-2-61-0
PROSEDUR ARTROSKOPI
880.806
907.230
924.847
942.463
143
M-2-62-0
179.700
185.092
188.686
192.280
885.571
912.138
929.850
947.561
1.207.736
1.243.968
1.268.123
1.292.277
179.700
185.092
188.686
192.280
891.627
918.375
936.208
954.040
860.458
886.271
903.481
920.690

DAN WAJAH
PAHA
PAHA

TULANG
WAJAH
WAJAH
BAWAH
BAWAH
144
M-2-63-0
145
M-2-64-0
146
M-2-65-0
147
M-2-71-0
148
M-2-72-0
149
M-2-81-0
1.283.126
1.321.619
1.347.282
1.372.944
150
M-2-82-0
932.108
960.072
978.714
997.356
151
M-2-83-0
179.700
185.092
188.686
192.280
152
M-2-84-0
179.700
185.092
188.686
192.280
153
M-3-10-0
512.900
528.287
538.545
548.803
154
M-3-11-0
284.372
292.903
298.590
304.278
155
M-3-12-0
643.085
662.377
675.239
688.101
156
M-3-13-0
209.663
215.953
220.146
224.339
157
M-3-14-0

TERTUTUP
358.350
369.100
376.267
383.434
158
M-3-15-0
157.875
162.611
165.769
168.926
159
M-3-16-0

179.700
185.092
188.686
192.280
160
M-3-17-0
196.188
202.074
205.997
209.921
161
N-2-11-0
2.374.020
2.445.241
2.492.721
2.540.201

PERGELANGAN TANGAN
PERGELANGAN TANGAN
MUSKULOSKELETAL
SKELETAL
- 971 No
Kode
INA-CBG
162
N-2-12-0
163
N-2-21-0
164
N-2-22-0
165
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.373.347
1.414.548
1.442.014
1.469.481
1.366.108
1.407.091
1.434.413
1.461.736
309.116
318.389
324.572
330.754
N-2-23-0
309.116
318.389
324.572
330.754
166
N-2-24-0
998.959
1.028.928
1.048.907
1.068.886
167
N-2-31-0
840.961
866.190
883.010
899.829
168
N-2-32-0
309.116
318.389
324.572
330.754
169
N-2-41-0
309.116
318.389
324.572
330.754
170
N-2-42-0
522.774
538.457
548.913
559.368
171
N-3-10-0
309.116
318.389
324.572
330.754
172
N-3-11-0
358.155
368.900
376.063
383.226
173
N-3-12-0
276.762
285.065
290.600
296.135
174
N-3-13-0
309.116
318.389
324.572
330.754
175
N-3-14-0
265.977
273.957
279.276
284.596
176
N-3-15-0
682.033
702.494
716.135
729.775
177
O-7-10-0
113.870
117.286
119.564
121.841
178
O-7-11-0
627.113
645.926
658.469
671.011
179
O-7-12-0
228.353
235.204
239.771
244.338
180
O-7-13-0
126.909
130.716
133.254
135.792
181
P-9-10-0
169.264
174.342
177.727
181.113
182
P-9-11-0
169.264
174.342
177.727
181.113
183
P-9-12-0
169.264
174.342
177.727
181.113
184
P-9-13-0
169.264
174.342
177.727
181.113
185
P-9-14-0
169.264
174.342
177.727
181.113
186
P-9-15-0
107.893
111.129
113.287
115.445
187
P-9-16-0
169.264
174.342
177.727
181.113
188
P-9-17-0
168.536
173.592
176.963
180.334
189
Q-5-10-0
220.605
227.223
231.635
236.048
190
Q-5-11-0
165.338
170.298
173.604
176.911
191
Q-5-12-0
GIGI
145.724
150.096
153.010
155.925
192
Q-5-13-0
MEDICAL CHECK-UP
110.744
114.066
116.281
118.496
193
Q-5-14-0
121.855
125.510
127.947
130.384


DAN URETHRA
DAN URETHRA
TRANSURETHRA
TRANSURETHRA
SALURAN KEMIH
KEMIH
KEMIH
PROSEDUR DIALISIS
CAESAR
VAGINAL/JALAN LAHIR

ASPIRASI
- 972 No
Kode
INA-CBG
194
Q-5-15-0
195
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
83.799
86.313
87.989
89.665
Q-5-16-0
VAKSINASI
94.713
97.554
99.448
101.342
196
Q-5-17-0
PASANG INFUS
81.924
84.382
86.020
87.659
197
Q-5-18-0
154.206
158.833
161.917
165.001
198
Q-5-19-0
172.394
177.565
181.013
184.461
199
Q-5-20-0
ABORSI MENGANCAM
115.550
119.016
121.327
123.638
200
Q-5-21-0
ABORSI
113.976
117.395
119.675
121.954
201
Q-5-22-0
121.855
125.510
127.947
130.384
202
Q-5-23-0
149.182
153.658
156.641
159.625
203
Q-5-24-0
101.889
104.946
106.984
109.022
204
Q-5-25-0
158.894
163.661
166.839
170.017
205
Q-5-26-0
BRONKIAL AKUT
224.904
231.651
236.149
240.647
206
Q-5-27-0
160.053
164.854
168.055
171.256
207
Q-5-28-0
129.879
133.775
136.372
138.970
208
Q-5-29-0

JANTUNG LAIN-LAIN
367.708
378.739
386.093
393.447
209
Q-5-30-0
426.133
438.917
447.440
455.963
210
Q-5-31-0
FRAKTUR
152.027
156.588
159.629
162.669
211
Q-5-32-0
SALURAN KEMIH AKUT
176.082
181.364
184.886
188.408
212
Q-5-33-0
HEMATOLOGI AKUT
184.357
189.888
193.575
197.262
213
Q-5-34-0
INFEKSI VIRUS HIV
261.892
269.749
274.987
280.225
214
Q-5-35-0
INFEKSI AKUT
296.979
305.888
311.828
317.767
215
Q-5-36-0
345.851
356.226
363.143
370.060
216
Q-5-37-0

SHOCK
176.402
181.694
185.222
188.750
217
Q-5-38-0
PARU AKUT
235.237
242.294
246.999
251.704
218
Q-5-39-0
150.534
155.051
158.061
161.072
219
Q-5-40-0
147.698
152.129
155.083
158.037
220
Q-5-41-0
204.468
210.602
214.691
218.780
221
Q-5-42-0
160.311
165.120
168.326
171.532
222
Q-5-43-0
230.857
237.782
242.400
247.017
223
Q-5-44-0
188.411
194.063
197.832
201.600
224
T-2-10-0

TERAPI DETOKSIKASI
97.726
100.657
102.612
104.566
225
U-2-10-0
1.304.259
1.343.387
1.369.472
1.395.557
226
U-2-11-0

LEHER
1.550.257
1.596.765
1.627.770
1.658.775
227
U-2-12-0
170.569
175.686
179.097
182.509
- 973 No
Kode
INA-CBG
228
U-2-13-0
229
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
223.620
230.328
234.801
239.273
U-2-14-0
415.384
427.846
436.153
444.461
230
U-2-15-0
236.012
243.093
247.813
252.533
231
U-2-21-0
274.917
283.165
288.663
294.162
232
U-2-22-0
531.163
547.097
557.721
568.344
233
U-2-23-0
695.995
716.874
730.794
744.714
234
U-2-24-0
586.572
604.169
615.901
627.632
235
U-2-25-0
223.620
230.328
234.801
239.273
236
U-2-31-0
179.700
185.092
188.686
192.280
237
U-2-32-0
223.620
230.328
234.801
239.273
238
U-3-10-0
213.792
220.206
224.482
228.758
239
U-3-11-0
226.981
233.790
238.330
242.869
240
U-3-12-0
100.371
103.382
105.389
107.397
241
U-3-13-0
220.622
227.241
231.654
236.066
242
U-3-14-0
202.707
208.788
212.842
216.896
243
U-3-15-0
176.778
182.082
185.617
189.153
244
U-3-16-0
PROSEDUR PADA GIGI
199.374
205.355
209.342
213.330
245
V-2-10-0

PROSTAT
1.945.121
2.003.474
2.042.377
2.081.279
246
V-2-11-0
219.360
225.941
230.328
234.715
700.009
721.010
735.010
749.010
309.116
318.389
324.572
330.754
309.116
318.389
324.572
330.754

(RHINOPLASTY)

RONGGA HIDUNG
TENGGOROKAN
PROSEDUR PADA PENIS

SKROTUM
SKROTUM
TRANSURETHRAL
247
V-2-12-0
248
V-2-13-0
249
V-2-14-0
250
V-2-15-0
SIRKUMSISI/SUNAT
169.264
174.342
177.727
181.113
251
V-3-10-0
353.012
363.602
370.662
377.723
252
V-3-11-0
746.803
769.207
784.143
799.079
253
V-3-12-0
431.149
444.083
452.706
461.329
254
W-2-10-0
157.875
162.611
165.769
168.926
255
W-2-11-0
403.469
415.573
423.643
431.712
256
W-2-12-0
746.803
769.207
784.143
799.079
257
W-2-13-0
119.774
123.367
125.763
128.158
258
W-2-21-0
1.501.273
1.546.311
1.576.336
1.606.362
259
W-2-22-0
157.875
162.611
165.769
168.926

PROSEDUR ABORSI
RAHIM & LEHER RAHIM
TERHALANG/TERGANGGU
TERHALANG/TERGANGGU
PANGGUL TERBUKA
PANGGUL TERBUKA
- 974 No
Kode
INA-CBG
260
W-2-23-0
Deskripsi (INA-CBG)
JALAN LAHIR
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
526.836
542.641
553.178
563.715
1.729.443
1.781.326
1.815.915
1.850.504
1.212.937
1.249.325
1.273.584
1.297.842
261
W-2-31-0
262
W-2-32-0
263
W-2-33-0
515.514
530.980
541.290
551.600
264
W-2-34-0
175.335
180.595
184.102
187.609
265
W-3-10-0
426.133
438.917
447.440
455.962
266
W-3-11-0
340.638
350.858
357.670
364.483
267
W-3-12-0
157.875
162.611
165.769
168.926
268
Z-3-10-0
1.787.354
1.840.975
1.876.722
1.912.469
269
Z-3-11-0

EMPEDU
1.366.108
1.407.091
1.434.413
1.461.736
270
Z-3-12-0
228.107
234.950
239.512
244.074
271
Z-3-13-0

LAIN-LAIN
1.391.971
1.433.731
1.461.570
1.489.409
272
Z-3-14-0
DIAGNOSTIK TIDUR
275.236
283.493
288.998
294.502
273
Z-3-15-0
179.700
185.092
188.686
192.280
274
Z-3-16-0

(MRI)
576.784
594.088
605.623
617.159
275
Z-3-17-0
PENGOBATAN NUKLIR
242.146
249.411
254.254
259.097
276
Z-3-18-0
CT-SCAN KEPALA
233.303
240.302
244.969
249.635
277
Z-3-19-0
CT SCAN LAIN-LAIN
242.823
250.108
254.965
259.821
278
Z-3-20-0
165.150
170.105
173.408
176.711
279
Z-3-21-0
157.875
162.611
165.769
168.926
280
Z-3-22-0
177.990
183.329
186.889
190.449
281
Z-3-23-0
185.392
190.953
194.661
198.369
282
Z-3-24-0
364.258
375.186
382.471
389.756
283
Z-3-25-0
162.240
167.107
170.352
173.597
284
Z-3-26-0
183.363
188.864
192.531
196.199
285
Z-3-27-0
PERAWATAN LUKA
175.062
180.314
183.815
187.316
286
Z-3-28-0
IMAGING PAYUDARA
179.700
185.092
188.686
192.280
287
Z-3-29-0
IMAGING LAIN-LAIN
517.929
533.467
543.826
554.184
288
Z-3-30-0
FOTOTERAPI
87.407
90.029
91.778
93.526
- 975 4. RUMAH SAKIT ORTOPEDIKELAS D

a. RawatInap
No
Kode
INA-CBG
A-4-10-i
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
SEPTIKEMIA RINGAN
1.333.090
1.373.083
1.399.744
1.426.406
A-4-10-ii
SEPTIKEMIA SEDANG
2.278.370
2.346.721
2.392.288
2.437.856
A-4-10-iii
SEPTIKEMIA BERAT
3.261.755
3.359.608
3.424.843
3.490.078
A-4-11-i
3.577.052
3.684.363
3.755.904
3.827.445
A-4-11-ii

SEDANG
5.526.131
5.691.915
5.802.438
5.912.961
A-4-11-iii
6.194.333
6.380.163
6.504.050
6.627.937
A-4-12-i
DEMAM RINGAN
1.281.320
1.319.759
1.345.386
1.371.012
A-4-12-ii
DEMAM SEDANG
2.012.608
2.072.986
2.113.239
2.153.491
A-4-12-iii
DEMAM BERAT
2.303.282
2.372.381
2.418.447
2.464.512
10
A-4-13-i
1.601.650
1.649.699
1.681.732
1.713.765
11
A-4-13-ii
1.921.980
1.979.639
2.018.079
2.056.518
12
A-4-13-iii
2.335.939
2.406.017
2.452.736
2.499.455
13
A-4-14-i
1.281.320
1.319.759
1.345.386
1.371.012
14
A-4-14-ii
2.001.811
2.061.865
2.101.901
2.141.937
15
A-4-14-iii
2.233.962
2.300.981
2.345.660
2.390.340
16
A-4-15-i
INFEKSI HIV RINGAN
1.921.980
1.979.639
2.018.079
2.056.518
17
A-4-15-ii
INFEKSI HIV SEDANG
2.882.970
2.969.459
3.027.118
3.084.778
18
A-4-15-iii
INFEKSI HIV BERAT
4.390.968
4.522.697
4.610.517
4.698.336
19
B-1-01-i
21.308.142
21.947.386
22.373.549
22.799.712
20
B-1-01-ii
23.508.577
24.213.835
24.684.006
25.154.178
21
B-1-01-iii
41.238.882
42.476.049
43.300.826
44.125.604
22
B-1-10-i
2.762.528
2.845.404
2.900.655
2.955.905
23
B-1-10-ii
7.040.253
7.251.460
7.392.265
7.533.070
24
B-1-10-iii
13.420.076
13.822.678
14.091.080
14.359.481
25
B-1-11-i
2.068.211
2.130.258
2.171.622
2.212.986
26
B-1-11-ii
5.191.406
5.347.148
5.450.976
5.554.804
27
B-1-11-iii
6.508.734
6.703.996
6.834.171
6.964.346
28
B-1-12-i
4.411.569
4.543.916
4.632.148
4.720.379
29
B-1-12-ii
9.455.072
9.738.725
9.927.826
10.116.927
30
B-1-12-iii
11.507.179
11.852.395
12.082.538
12.312.682

LAIN-LAIN RINGAN
LAIN-LAIN SEDANG
LAIN-LAIN BERAT

(RINGAN)
(SEDANG)
(BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT
- 976 No
Kode
INA-CBG
31
B-1-13-i
32
B-1-13-ii
33
B-1-13-iii
34
B-1-14-i
35
B-1-14-ii
36
B-1-14-iii
37
B-4-10-i
38
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.890.803
2.977.527
3.035.343
3.093.159
4.708.699
4.849.960
4.944.134
5.038.308
6.941.944
7.150.202
7.289.041
7.427.880
3.925.507
4.043.273
4.121.783
4.200.293
4.365.956
4.496.935
4.584.254
4.671.573
6.830.020
7.034.920
7.171.521
7.308.121
1.098.297
1.131.246
1.153.212
1.175.178
B-4-10-ii
1.601.650
1.649.699
1.681.732
1.713.765
39
B-4-10-iii
2.681.686
2.762.137
2.815.771
2.869.404
40
B-4-11-i
2.651.701
2.731.252
2.784.286
2.837.320
41
B-4-11-ii
4.031.248
4.152.185
4.232.810
4.313.435
42
B-4-11-iii
4.341.794
4.472.048
4.558.884
4.645.720
43
B-4-12-i
2.326.686
2.396.487
2.443.020
2.489.554
44
B-4-12-ii
3.298.668
3.397.628
3.463.602
3.529.575
45
B-4-12-iii
6.269.042
6.457.114
6.582.495
6.707.875
46
B-4-13-i
1.921.980
1.979.639
2.018.079
2.056.518
47
B-4-13-ii
2.278.081
2.346.423
2.391.985
2.437.546
48
B-4-13-iii
4.049.866
4.171.362
4.252.360
4.333.357
49
B-4-14-i
2.014.902
2.075.349
2.115.648
2.155.946
50
B-4-14-ii
2.264.195
2.332.121
2.377.405
2.422.688
51
B-4-14-iii
2.991.467
3.081.211
3.141.040
3.200.869
52
C-4-10-i
2.049.672
2.111.162
2.152.156
2.193.149
53
C-4-10-ii
3.982.298
4.101.767
4.181.413
4.261.059
54
C-4-10-iii
LEUKEMIA AKUT BERAT
6.086.269
6.268.857
6.390.583
6.512.308
55
C-4-11-i
2.061.963
2.123.822
2.165.061
2.206.301
56
C-4-11-ii
2.562.640
2.639.519
2.690.772
2.742.024
57
C-4-11-iii
4.771.259
4.914.397
5.009.822
5.105.248
58
C-4-12-i
RADIOTERAPI RINGAN
1.281.320
1.319.759
1.345.386
1.371.012
59
C-4-12-ii
RADIOTERAPI SEDANG
3.863.474
3.979.379
4.056.648
4.133.918
60
C-4-12-iii
RADIOTERAPI BERAT
7.843.627
8.078.936
8.235.809
8.392.681
61
C-4-13-i
KEMOTERAPI RINGAN
1.281.320
1.319.759
1.345.386
1.371.012
62
C-4-13-ii
KEMOTERAPI SEDANG
2.562.640
2.639.519
2.690.772
2.742.024
63
C-4-13-iii
KEMOTERAPI BERAT
3.353.024
3.453.615
3.520.676
3.587.736

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT

PANCREAS RINGAN
PANCREAS SEDANG
PANCREAS BERAT
(RINGAN)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT
- 977 No
Kode
INA-CBG
64
C-4-14-i
65
C-4-14-ii
66
C-4-14-iii
67
D-1-10-i
68
D-1-10-ii
69
D-1-10-iii
70
D-1-11-i
71
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.819.594
1.874.182
1.910.574
1.946.966
2.658.908
2.738.675
2.791.853
2.845.031
4.053.428
4.175.031
4.256.099
4.337.168
13.634.763
14.043.806
14.316.501
14.589.196
20.766.789
21.389.793
21.805.129
22.220.465
28.144.674
28.989.014
29.551.908
30.114.801
3.069.118
3.161.191
3.222.574
3.283.956
D-1-11-ii
8.004.823
8.244.967
8.405.064
8.565.160
72
D-1-11-iii
11.013.395
11.343.797
11.564.065
11.784.333
73
D-1-20-i
3.452.099
3.555.662
3.624.704
3.693.746
74
D-1-20-ii
7.767.223
8.000.240
8.155.584
8.310.929
75
D-1-20-iii
15.102.934
15.556.022
15.858.081
16.160.140
76
D-4-10-i
1.230.786
1.267.710
1.292.326
1.316.941
77
D-4-10-ii
2.485.189
2.559.745
2.609.449
2.659.153
78
D-4-10-iii
3.203.300
3.299.399
3.363.465
3.427.531
79
D-4-11-i
1.601.650
1.649.699
1.681.732
1.713.765
80
D-4-11-ii
2.953.007
3.041.597
3.100.658
3.159.718
81
D-4-11-iii
4.473.395
4.607.597
4.697.064
4.786.532
82
D-4-12-i
1.642.987
1.692.277
1.725.136
1.757.996
83
D-4-12-ii
2.278.985
2.347.354
2.392.934
2.438.513
84
D-4-12-iii
3.499.382
3.604.364
3.674.351
3.744.339
85
D-4-13-i
1.281.320
1.319.759
1.345.386
1.371.012
86
D-4-13-ii
1.921.980
1.979.639
2.018.079
2.056.518
87
D-4-13-iii
2.242.310
2.309.579
2.354.425
2.399.271
88
D-4-14-i
1.601.650
1.649.699
1.681.732
1.713.765
89
D-4-14-ii
3.604.475
3.712.609
3.784.699
3.856.788
90
D-4-14-iii
4.299.640
4.428.629
4.514.622
4.600.615
91
E-1-01-i
3.363.655
3.464.564
3.531.837
3.599.110
92
E-1-01-ii
4.406.068
4.538.250
4.626.371
4.714.492
93
E-1-01-iii
9.118.946
9.392.515
9.574.894
9.757.272
94
E-1-10-i
3.129.652
3.223.542
3.286.135
3.348.728
95
E-1-10-ii
3.798.663
3.912.623
3.988.597
4.064.570
96
E-1-10-iii
8.006.464
8.246.658
8.406.787
8.566.917

RINGAN
SEDANG
BERAT
TULANG RINGAN
TULANG SEDANG
TULANG BERAT


RINGAN
SEDANG
BERAT
- 978 No
Kode
INA-CBG
97
E-1-20-i
98
E-1-20-ii
99
E-1-20-iii
100
E-4-10-i
101
E-4-10-ii
102
E-4-10-iii
103
E-4-11-i
104
E-4-11-ii
105
E-4-11-iii
106
E-4-12-i
107
E-4-12-ii
108
E-4-12-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.968.982
4.088.051
4.167.431
4.246.810
5.315.810
5.475.284
5.581.600
5.687.916
11.778.332
12.131.682
12.367.248
12.602.815
1.628.584
1.677.442
1.710.014
1.742.585
2.494.584
2.569.421
2.619.313
2.669.205
4.354.129
4.484.753
4.571.835
4.658.918
1.496.545
1.541.441
1.571.372
1.601.303
2.831.206
2.916.142
2.972.766
3.029.390
4.668.789
4.808.852
4.902.228
4.995.604
1.761.815
1.814.669
1.849.906
1.885.142
2.882.970
2.969.459
3.027.118
3.084.778
4.631.833
4.770.788
4.863.425
4.956.062
1.886.161
1.942.746
1.980.469
2.018.192
3.238.551
3.335.708
3.400.479
3.465.250
5.603.512
5.771.617
5.883.687
5.995.758

RINGAN
SEDANG
BERAT

RINGAN
SEDANG
BERAT
109
E-4-13-i
110
E-4-13-ii
111
E-4-13-iii
112
F-4-10-i
SCHIZOFRENIA RINGAN
2.306.188
2.375.374
2.421.498
2.467.622
113
F-4-10-ii
SCHIZOFRENIA SEDANG
2.561.096
2.637.929
2.689.151
2.740.373
114
F-4-10-iii
SCHIZOFRENIA BERAT
3.791.760
3.905.512
3.981.348
4.057.183
115
F-4-11-i
2.125.747
2.189.519
2.232.034
2.274.549
116
F-4-11-ii
2.476.697
2.550.998
2.600.532
2.650.066
117
F-4-11-iii
DEPRESI MAYOR BERAT
3.176.031
3.271.312
3.334.832
3.398.353
1.038.076
1.069.219
1.089.980
1.110.742
1.372.157
1.413.322
1.440.765
1.468.208
2.976.665
3.065.965
3.125.498
3.185.031

IMPULSE RINGAN
IMPULSE SEDANG
IMPULSE BERAT
118
F-4-12-i
119
F-4-12-ii
120
F-4-12-iii
121
F-4-13-i
1.717.927
1.769.464
1.803.823
1.838.181
122
F-4-13-ii
2.274.976
2.343.226
2.388.725
2.434.225
123
F-4-13-iii
2.933.292
3.021.290
3.079.956
3.138.622
124
F-4-14-i
DEPRESI RINGAN
1.202.549
1.238.625
1.262.676
1.286.727
125
F-4-14-ii
DEPRESI SEDANG
1.542.513
1.588.788
1.619.638
1.650.488
126
F-4-14-iii
DEPRESI BERAT
2.075.519
2.137.785
2.179.295
2.220.806
127
F-4-15-i
1.429.762
1.472.655
1.501.250
1.529.845
128
F-4-15-ii
2.012.809
2.073.193
2.113.449
2.153.705
129
F-4-15-iii
2.531.365
2.607.306
2.657.933
2.708.561
- 979 No
Kode
INA-CBG
130
F-4-16-i
131
F-4-16-ii
132
F-4-16-iii
133
F-4-17-i
134
F-4-17-ii
135
F-4-17-iii
136
F-4-18-i
137
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.079.427
3.171.810
3.233.399
3.294.987
3.579.757
3.687.150
3.758.745
3.830.340
4.778.378
4.921.730
5.017.297
5.112.865
649.240
668.717
681.702
694.686
1.902.859
1.959.945
1.998.002
2.036.059
2.030.211
2.091.117
2.131.721
2.172.326
2.669.144
2.749.218
2.802.601
2.855.984
F-4-18-ii
2.936.812
3.024.917
3.083.653
3.142.389
138
F-4-18-iii
4.527.352
4.663.172
4.753.720
4.844.267
139
F-4-19-i
2.046.981
2.108.391
2.149.331
2.190.270
140
F-4-19-ii
2.621.213
2.699.849
2.752.273
2.804.697
141
F-4-19-iii
3.263.445
3.361.348
3.426.617
3.491.886
142
G-1-01-i
5.942.469
6.120.743
6.239.593
6.358.442
143
G-1-01-ii
10.058.345
10.360.095
10.561.262
10.762.429
144
G-1-01-iii
19.471.833
20.055.988
20.445.424
20.834.861
145
G-1-10-i
3.247.716
3.345.147
3.410.102
3.475.056
146
G-1-10-ii
4.584.968
4.722.517
4.814.216
4.905.915
147
G-1-10-iii
5.434.166
5.597.191
5.705.874
5.814.557
148
G-1-11-i
3.746.337
3.858.727
3.933.654
4.008.581
149
G-1-11-ii
7.693.386
7.924.188
8.078.055
8.231.923
150
G-1-11-iii
16.109.251
16.592.528
16.914.713
17.236.898
151
G-1-12-i
2.913.547
3.000.953
3.059.224
3.117.495
152
G-1-12-ii
6.670.275
6.870.383
7.003.789
7.137.194
153
G-1-12-iii
11.484.302
11.828.831
12.058.517
12.288.203
154
G-1-13-i
701.644
722.693
736.726
750.759
155
G-1-13-ii
1.884.539
1.941.075
1.978.765
2.016.456
156
G-1-13-iii
4.252.313
4.379.882
4.464.928
4.549.975
3.671.317
3.781.456
3.854.882
3.928.309
4.960.069
5.108.871
5.208.073
5.307.274
12.144.146
12.508.470
12.751.353
12.994.236

RINGAN
SEDANG
BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

RINGAN
SEDANG
BERAT
157
G-1-20-i
158
G-1-20-ii
159
G-1-20-iii
160
G-1-30-i
4.682.434
4.822.907
4.916.556
5.010.204
161
G-1-30-ii
12.221.601
12.588.249
12.832.681
13.077.113
162
G-1-30-iii
15.732.978
16.204.967
16.519.627
16.834.286
- 980 No
Kode
INA-CBG
163
G-4-10-i
164
G-4-10-ii
165
G-4-10-iii
166
G-4-11-i
167
G-4-11-ii
168
G-4-11-iii
169
G-4-12-i
170
G-4-12-ii
171
G-4-12-iii
172
G-4-13-i
173
G-4-13-ii
174
G-4-13-iii
175
G-4-14-i
176
G-4-14-ii
177
G-4-14-iii
178
G-4-15-i
179
G-4-15-ii
180
G-4-15-iii
181
G-4-16-i
182
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.921.980
1.979.639
2.018.079
2.056.518
2.242.310
2.309.579
2.354.425
2.399.271
3.751.516
3.864.061
3.939.092
4.014.122
3.472.806
3.576.990
3.646.447
3.715.903
4.028.455
4.149.309
4.229.878
4.310.447
5.903.771
6.080.884
6.198.959
6.317.035
2.597.353
2.675.274
2.727.221
2.779.168
3.272.665
3.370.845
3.436.299
3.501.752
4.753.157
4.895.751
4.990.815
5.085.878
1.445.150
1.488.505
1.517.408
1.546.311
2.242.310
2.309.579
2.354.425
2.399.271
2.650.728
2.730.250
2.783.265
2.836.279
2.642.964
2.722.253
2.775.112
2.827.971
4.348.568
4.479.025
4.565.996
4.652.967
5.444.506
5.607.841
5.716.731
5.825.621
1.921.980
1.979.639
2.018.079
2.056.518
2.436.638
2.509.737
2.558.469
2.607.202
3.688.418
3.799.071
3.872.839
3.946.607
1.601.650
1.649.699
1.681.732
1.713.765
G-4-16-ii
2.395.282
2.467.140
2.515.046
2.562.952
183
G-4-16-iii
4.347.008
4.477.419
4.564.359
4.651.299
184
G-4-17-i
2.506.653
2.581.853
2.631.986
2.682.119
185
G-4-17-ii
3.110.867
3.204.193
3.266.410
3.328.628
186
G-4-17-iii
5.213.838
5.370.254
5.474.530
5.578.807
187
G-4-18-i
1.921.980
1.979.639
2.018.079
2.056.518
188
G-4-18-ii
3.017.951
3.108.490
3.168.849
3.229.208
189
G-4-18-iii
3.197.212
3.293.128
3.357.072
3.421.017
190
G-4-19-i
1.753.082
1.805.674
1.840.736
1.875.798
191
G-4-19-ii
3.245.959
3.343.337
3.408.257
3.473.176

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
DEGENERATIF RINGAN
DEGENERATIF SEDANG
DEGENERATIF BERAT
RINGAN
SEDANG
BERAT
TRAUMATIK RINGAN
TRAUMATIK SEDANG
TRAUMATIK BERAT
DENGAN INFARK BERAT
TANPA INFARK RINGAN
TANPA INFARK SEDANG
TANPA INFARK BERAT

PERIFER RINGAN
PERIFER SEDANG
PERIFER BERAT
PERSARAFAN RINGAN
PERSARAFAN SEDANG
PERSARAFAN BERAT
RINGAN
SEDANG
- 981 No
Kode
INA-CBG
192
G-4-19-iii
193
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

4.841.940
4.987.198
5.084.037
5.180.876
G-4-20-i
1.121.155
1.154.790
1.177.213
1.199.636
194
G-4-20-ii
1.592.041
1.639.802
1.671.643
1.703.484
195
G-4-20-iii
2.714.803
2.796.247
2.850.543
2.904.839
196
G-4-21-i
1.422.755
1.465.437
1.493.892
1.522.347
197
G-4-21-ii
2.946.667
3.035.067
3.094.000
3.152.934
198
G-4-21-iii
3.471.521
3.575.667
3.645.097
3.714.528
199
G-4-22-i
1.281.320
1.319.759
1.345.386
1.371.012
200
G-4-22-ii
1.601.650
1.649.699
1.681.732
1.713.765
201
G-4-22-iii
1.837.511
1.892.636
1.929.387
1.966.137
202
G-4-23-i
1.281.320
1.319.759
1.345.386
1.371.012
203
G-4-23-ii
1.601.650
1.649.699
1.681.732
1.713.765
204
G-4-23-iii
2.289.445
2.358.128
2.403.917
2.449.706
205
G-4-24-i
1.281.320
1.319.759
1.345.386
1.371.012
206
G-4-24-ii
1.601.650
1.649.699
1.681.732
1.713.765
207
G-4-24-iii
TRAUMA KEPALA BERAT
3.365.694
3.466.665
3.533.978
3.601.292
208
G-4-25-i
GEGAR OTAK RINGAN
1.281.320
1.319.759
1.345.386
1.371.012
209
G-4-25-ii
GEGAR OTAK SEDANG
1.601.650
1.649.699
1.681.732
1.713.765
210
G-4-25-iii
GEGAR OTAK BERAT
1.999.964
2.059.963
2.099.962
2.139.962
211
G-4-26-i
2.114.646
2.178.086
2.220.379
2.262.672
212
G-4-26-ii
2.398.080
2.470.022
2.517.984
2.565.945
213
G-4-26-iii
4.280.256
4.408.663
4.494.268
4.579.873
214
H-1-20-i
2.016.969
2.077.479
2.117.818
2.158.157
215
H-1-20-ii
3.678.172
3.788.517
3.862.081
3.935.644
216
H-1-20-iii
5.002.084
5.152.147
5.252.189
5.352.230
1.974.805
2.034.049
2.073.545
2.113.042
2.251.278
2.318.816
2.363.842
2.408.867

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)

RINGAN
SEDANG
217
H-1-30-i
218
H-1-30-ii
219
H-1-30-iii
3.756.176
3.868.861
3.943.985
4.019.108
220
H-4-10-i
1.921.980
1.979.639
2.018.079
2.056.518
221
H-4-10-ii
3.203.300
3.299.399
3.363.465
3.427.531
222
H-4-10-iii
5.222.324
5.378.994
5.483.441
5.587.887
223
H-4-11-i
1.433.153
1.476.147
1.504.810
1.533.474
224
H-4-11-ii
1.581.926
1.629.383
1.661.022
1.692.660
225
H-4-11-iii
2.090.851
2.153.577
2.195.394
2.237.211
- 982 No
Kode
INA-CBG
226
H-4-12-i
227
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.988.442
2.048.096
2.087.864
2.127.633
H-4-12-ii
2.693.475
2.774.279
2.828.149
2.882.018
228
H-4-12-iii
4.493.880
4.628.696
4.718.574
4.808.451
229
I-1-01-i
27.642.940
28.472.229
29.025.087
29.577.946
230
I-1-01-ii
28.251.229
29.098.766
29.663.791
30.228.815
231
I-1-01-iii
44.594.023
45.931.844
46.823.725
47.715.605
232
I-1-02-i
15.336.144
15.796.228
16.102.951
16.409.674
233
I-1-02-ii
19.783.626
20.377.135
20.772.807
21.168.480
234
I-1-02-iii
24.384.469
25.116.003
25.603.693
26.091.382
235
I-1-03-i
9.444.543
9.727.879
9.916.770
10.105.661
236
I-1-03-ii
12.945.372
13.333.733
13.592.641
13.851.548
237
I-1-03-iii
18.986.546
19.556.142
19.935.873
20.315.604
238
I-1-04-i
12.618.189
12.996.734
13.249.098
13.501.462
239
I-1-04-ii
16.208.287
16.694.536
17.018.702
17.342.867
240
I-1-04-iii
34.552.703
35.589.284
36.280.338
36.971.393
241
I-1-05-i
20.297.838
20.906.773
21.312.730
21.718.686
242
I-1-05-ii
24.357.405
25.088.127
25.575.276
26.062.424
243
I-1-05-iii
33.515.636
34.521.105
35.191.418
35.861.731
244
I-1-06-i
10.478.173
10.792.519
11.002.082
11.211.646
245
I-1-06-ii
15.814.051
16.288.472
16.604.753
16.921.034
246
I-1-06-iii
18.589.840
19.147.535
19.519.332
19.891.128
13.779.591
14.192.979
14.468.571
14.744.163
16.999.925
17.509.923
17.849.922
18.189.920
18.546.808
19.103.212
19.474.148
19.845.085
2.621.214
2.699.851
2.752.275
2.804.699
2.914.528
3.001.964
3.060.255
3.118.545
3.878.349
3.994.699
4.072.266
4.149.833
7.335.711
7.555.782
7.702.496
7.849.211
10.178.641
10.484.001
10.687.573
10.891.146
247
I-1-07-i
248
I-1-07-ii
249
I-1-07-iii
250
I-1-11-i
251
I-1-11-ii
252
I-1-11-iii
253
I-1-12-i
254
I-1-12-ii

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
KATETERISASI RINGAN
KATETERISASI SEDANG
KATETERISASI BERAT
RINGAN
SEDANG
BERAT

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
- 983 No
Kode
INA-CBG
255
I-1-12-iii
256
I-1-13-i
257
I-1-13-ii
258
I-1-13-iii
259
I-1-14-i
260
I-1-14-ii
261
I-1-14-iii
262
I-1-15-i
263
I-1-15-ii
264
I-1-15-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
14.196.802
14.622.706
14.906.642
15.190.578
4.315.124
4.444.578
4.530.880
4.617.183
5.020.382
5.170.994
5.271.401
5.371.809
10.022.457
10.323.131
10.523.580
10.724.029
15.787.207
16.260.823
16.576.568
16.892.312
19.621.243
20.209.880
20.602.305
20.994.730
25.710.594
26.481.912
26.996.124
27.510.336
3.387.831
3.489.466
3.557.223
3.624.979
9.061.761
9.333.613
9.514.849
9.696.084
46.905.026
48.312.176
49.250.277
50.188.377
6.765.946
6.968.924
7.104.243
7.239.562
17.591.459
18.119.203
18.471.032
18.822.862
20.291.317
20.900.056
21.305.883
21.711.709
2.376.321
2.447.610
2.495.137
2.542.663
4.922.221
5.069.888
5.168.333
5.266.777
28.536.046
29.392.127
29.962.848
30.533.569
3.840.460
3.955.674
4.032.483
4.109.293
6.345.040
6.535.391
6.662.292
6.789.193
12.848.474
13.233.928
13.490.898
13.747.867
7.676.001
7.906.281
8.059.801
8.213.321
15.967.632
16.446.661
16.766.014
17.085.367
24.744.031
25.486.352
25.981.232
26.476.113
11.304.495
11.643.630
11.869.720
12.095.809
15.317.727
15.777.258
16.083.613
16.389.967
18.945.321
19.513.681
19.892.587
20.271.494

KOMPLEKS BERAT
KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

DARAH VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
265
I-1-16-i
266
I-1-16-ii
267
I-1-16-iii
268
I-1-17-i
269
I-1-17-ii
270
I-1-17-iii
271
I-1-20-i
272
I-1-20-ii
273
I-1-20-iii
274
I-1-30-i
275
I-1-30-ii
276
I-1-30-iii
277
I-1-40-i
278
I-1-40-ii
279
I-1-40-iii
280
I-4-10-i
3.287.676
3.386.306
3.452.059
3.517.813
281
I-4-10-ii
5.191.299
5.347.038
5.450.864
5.554.690
282
I-4-10-iii
7.488.901
7.713.568
7.863.346
8.013.124
283
I-4-11-i
3.898.324
4.015.273
4.093.240
4.171.206
- 984 No
Kode
INA-CBG
284
I-4-11-ii
285
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.804.949
4.949.098
5.045.197
5.141.296
I-4-11-iii
7.796.018
8.029.898
8.185.819
8.341.739
286
I-4-12-i
3.414.526
3.516.962
3.585.252
3.653.543
287
I-4-12-ii
4.872.519
5.018.695
5.116.145
5.213.595
288
I-4-12-iii
5.911.051
6.088.383
6.206.604
6.324.825
289
I-4-13-i
3.067.183
3.159.199
3.220.542
3.281.886
290
I-4-13-ii
4.455.991
4.589.671
4.678.791
4.767.911
291
I-4-13-iii
8.328.579
8.578.436
8.745.008
8.911.579
292
I-4-14-i
1.907.505
1.964.730
2.002.880
2.041.030
293
I-4-14-ii
2.232.062
2.299.024
2.343.666
2.388.307
294
I-4-14-iii
3.458.954
3.562.723
3.631.902
3.701.081
295
I-4-15-i
2.562.640
2.639.519
2.690.772
2.742.024
296
I-4-15-ii
4.017.543
4.138.070
4.218.421
4.298.771
297
I-4-15-iii
4.579.033
4.716.404
4.807.985
4.899.565
298
I-4-16-i
1.921.980
1.979.639
2.018.079
2.056.518
299
I-4-16-ii
3.114.867
3.208.313
3.270.611
3.332.908
300
I-4-16-iii
3.924.179
4.041.905
4.120.388
4.198.872
301
I-4-17-i
HIPERTENSI RINGAN
1.883.773
1.940.286
1.977.961
2.015.637
302
I-4-17-ii
HIPERTENSI SEDANG
2.569.809
2.646.903
2.698.299
2.749.695
303
I-4-17-iii
HIPERTENSI BERAT
3.003.590
3.093.698
3.153.770
3.213.842
304
I-4-18-i
2.774.256
2.857.483
2.912.969
2.968.454
305
I-4-18-ii
4.249.974
4.377.473
4.462.473
4.547.472
306
I-4-18-iii
5.729.646
5.901.536
6.016.129
6.130.722
307
I-4-19-i
2.171.219
2.236.355
2.279.780
2.323.204
308
I-4-19-ii
3.524.659
3.630.399
3.700.892
3.771.385
309
I-4-19-iii
4.037.385
4.158.506
4.239.254
4.320.002
310
I-4-20-i
2.635.082
2.714.134
2.766.836
2.819.537
311
I-4-20-ii
3.035.811
3.126.885
3.187.601
3.248.318
312
I-4-20-iii
4.029.026
4.149.897
4.230.477
4.311.058
313
I-4-21-i
3.504.232
3.609.359
3.679.443
3.749.528
314
I-4-21-ii
4.371.302
4.502.441
4.589.867
4.677.293
315
I-4-21-iii
5.963.383
6.142.284
6.261.552
6.380.820
316
I-4-22-i
2.082.145
2.144.609
2.186.252
2.227.895

VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT


RINGAN
SEDANG
KONGENITAL BERAT
RINGAN
SEDANG
BERAT
- 985 No
Kode
INA-CBG
317
I-4-22-ii
318
I-4-22-iii
319
I-4-23-i
320
I-4-23-ii
321
I-4-23-iii
322
I-4-24-i
323
I-4-24-ii
324
I-4-24-iii
325
J-1-01-i
326
J-1-01-ii
327
J-1-01-iii
328
J-1-02-i
329
J-1-02-ii
330
J-1-02-iii
331
J-1-10-i
332
J-1-10-ii
333
J-1-10-iii
334
J-1-20-i
335
J-1-20-ii
336
J-1-20-iii
337
J-1-30-i
338
J-1-30-ii
339
J-1-30-iii
340
J-4-10-i
341
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.399.254
2.471.232
2.519.217
2.567.202
3.500.446
3.605.460
3.675.469
3.745.478
1.577.342
1.624.662
1.656.209
1.687.756
1.936.613
1.994.711
2.033.443
2.072.175
3.783.964
3.897.483
3.973.163
4.048.842
2.060.288
2.122.096
2.163.302
2.204.508
5.143.968
5.298.287
5.401.167
5.504.046
6.503.619
6.698.727
6.828.800
6.958.872
16.599.104
17.097.078
17.429.060
17.761.042
17.732.763
18.264.746
18.619.401
18.974.056
30.296.530
31.205.426
31.811.356
32.417.287
8.485.133
8.739.687
8.909.390
9.079.092
9.089.838
9.362.533
9.544.330
9.726.127
13.432.191
13.835.157
14.103.800
14.372.444
3.311.022
3.410.352
3.476.573
3.542.793
7.997.320
8.237.240
8.397.186
8.557.133
14.160.239
14.585.046
14.868.250
15.151.455
2.861.782
2.947.636
3.004.871
3.062.107
4.162.236
4.287.103
4.370.348
4.453.593
6.258.718
6.446.479
6.571.653
6.696.828
1.929.858
1.987.753
2.026.351
2.064.948
8.630.248
8.889.156
9.061.761
9.234.365
26.028.449
26.809.303
27.329.872
27.850.441
2.033.830
2.094.845
2.135.522
2.176.198
J-4-10-ii
2.908.133
2.995.377
3.053.539
3.111.702
342
J-4-10-iii
4.399.571
4.531.558
4.619.549
4.707.541
343
J-4-11-i
1.405.151
1.447.306
1.475.409
1.503.512
344
J-4-11-ii
1.955.939
2.014.617
2.053.736
2.092.854
345
J-4-11-iii
2.802.910
2.886.997
2.943.056
2.999.114
346
J-4-12-i
EMBOLI PARU RINGAN
1.962.175
2.021.040
2.060.284
2.099.527
347
J-4-12-ii
EMBOLI PARU SEDANG
2.540.949
2.617.178
2.667.997
2.718.816

RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
- 986 No
Kode
INA-CBG
348
J-4-12-iii
349
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
EMBOLI PARU BERAT
3.393.181
3.494.976
3.562.840
3.630.704
J-4-13-i
3.310.032
3.409.333
3.475.533
3.541.734
350
J-4-13-ii
4.865.747
5.011.719
5.109.034
5.206.349
351
J-4-13-iii
7.910.976
8.148.305
8.306.525
8.464.744
352
J-4-14-i
TUMOR PARU RINGAN
2.255.682
2.323.353
2.368.466
2.413.580
353
J-4-14-ii
TUMOR PARU SEDANG
3.778.576
3.891.933
3.967.505
4.043.077
354
J-4-14-iii
TUMOR PARU BERAT
4.492.535
4.627.311
4.717.162
4.807.012
355
J-4-15-i
1.974.764
2.034.007
2.073.502
2.112.997
356
J-4-15-ii
2.780.585
2.864.002
2.919.614
2.975.226
357
J-4-15-iii
3.494.161
3.598.986
3.668.869
3.738.752
358
J-4-16-i
1.601.650
1.649.699
1.681.732
1.713.765
359
J-4-16-ii
2.321.509
2.391.155
2.437.585
2.484.015
360
J-4-16-iii
4.044.891
4.166.238
4.247.135
4.328.033
361
J-4-17-i
1.616.727
1.665.229
1.697.563
1.729.898
362
J-4-17-ii
2.194.367
2.260.198
2.304.086
2.347.973
363
J-4-17-iii
3.533.449
3.639.453
3.710.122
3.780.791
364
J-4-18-i
1.281.320
1.319.759
1.345.386
1.371.012
365
J-4-18-ii
1.761.815
1.814.669
1.849.906
1.885.142
366
J-4-18-iii
1.855.083
1.910.736
1.947.837
1.984.939
367
J-4-19-i
2.242.310
2.309.579
2.354.425
2.399.271
368
J-4-19-ii
2.780.564
2.863.981
2.919.592
2.975.204
369
J-4-19-iii
4.014.675
4.135.116
4.215.409
4.295.703
370
J-4-20-i
2.261.611
2.329.460
2.374.692
2.419.924
371
J-4-20-ii
2.995.410
3.085.272
3.145.181
3.205.089
372
J-4-20-iii
6.180.574
6.365.991
6.489.602
6.613.214
373
J-4-21-i
1.281.320
1.319.759
1.345.386
1.371.012
374
J-4-21-ii
3.161.250
3.256.087
3.319.312
3.382.537
375
J-4-21-iii
4.508.976
4.644.246
4.734.425
4.824.605
376
K-1-10-i
3.452.099
3.555.662
3.624.704
3.693.746
377
K-1-10-ii
5.275.944
5.434.223
5.539.742
5.645.261
378
K-1-10-iii
6.179.039
6.364.411
6.487.991
6.611.572
379
K-1-11-i
3.250.654
3.348.173
3.413.186
3.478.200
380
K-1-11-ii
4.267.716
4.395.748
4.481.102
4.566.456

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT

USUS BESAR (RINGAN)
USUS BESAR (SEDANG)
USUS BESAR (BERAT)
- 987 No
Kode
INA-CBG
381
K-1-11-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
10.830.623
11.155.542
11.372.155
11.588.767
1.748.603
1.801.061
1.836.033
1.871.005
2.278.970
2.347.340
2.392.919
2.438.498
4.533.351
4.669.352
4.760.019
4.850.686
382
K-1-12-i
383
K-1-12-ii
384
K-1-12-iii
385
K-1-13-i
1.986.173
2.045.758
2.085.482
2.125.205
386
K-1-13-ii
3.469.274
3.573.352
3.642.738
3.712.123
387
K-1-13-iii
3.710.264
3.821.571
3.895.777
3.969.982
3.209.773
3.306.067
3.370.262
3.434.458
3.770.243
3.883.350
3.958.755
4.034.160
9.283.430
9.561.933
9.747.602
9.933.271

RINGAN
SEDANG
BERAT
388
K-1-14-i
389
K-1-14-ii
390
K-1-14-iii
391
K-1-20-i
6.227.902
6.414.739
6.539.297
6.663.855
392
K-1-20-ii
8.692.509
8.953.284
9.127.134
9.300.985
393
K-1-20-iii
18.567.610
19.124.638
19.495.990
19.867.342
394
K-1-30-i
4.099.515
4.222.501
4.304.491
4.386.481
395
K-1-30-ii
6.904.198
7.111.324
7.249.408
7.387.492
396
K-1-30-iii
11.775.306
12.128.565
12.364.072
12.599.578
397
K-1-40-i
4.118.458
4.242.012
4.324.381
4.406.750
398
K-1-40-ii
4.531.954
4.667.912
4.758.551
4.849.191
399
K-1-40-iii
7.515.809
7.741.283
7.891.599
8.041.916
400
K-1-50-i
3.141.390
3.235.631
3.298.459
3.361.287
401
K-1-50-ii
4.068.248
4.190.295
4.271.660
4.353.025
402
K-1-50-iii
PROSEDUR ANAL BERAT
5.775.830
5.949.105
6.064.621
6.180.138
403
K-4-10-i
2.379.377
2.450.758
2.498.346
2.545.933
404
K-4-10-ii
2.847.064
2.932.476
2.989.417
3.046.358
405
K-4-10-iii
10.765.506
11.088.471
11.303.781
11.519.091
406
K-4-11-i
1.281.320
1.319.759
1.345.386
1.371.012
407
K-4-11-ii
1.921.980
1.979.639
2.018.079
2.056.518
408
K-4-11-iii
3.492.930
3.597.718
3.667.576
3.737.435
409
K-4-12-i
1.281.320
1.319.759
1.345.386
1.371.012
410
K-4-12-ii
2.096.381
2.159.273
2.201.200
2.243.128
411
K-4-12-iii
5.031.166
5.182.101
5.282.724
5.383.348
412
K-4-13-i

(RINGAN)
1.921.980
1.979.639
2.018.079
2.056.518

(RINGAN)
(SEDANG)
(BERAT)
- 988 No
Kode
INA-CBG
413
K-4-13-ii
414
K-4-13-iii
415
K-4-14-i
416
K-4-14-ii
417
K-4-14-iii
418
K-4-15-i
419
K-4-15-ii
420
K-4-15-iii
421
K-4-16-i
422
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.489.437
2.564.120
2.613.909
2.663.698
4.071.630
4.193.778
4.275.211
4.356.644
1.601.650
1.649.699
1.681.732
1.713.765
2.167.666
2.232.696
2.276.049
2.319.402
3.278.801
3.377.165
3.442.741
3.508.317
1.601.650
1.649.699
1.681.732
1.713.765
3.011.538
3.101.885
3.162.115
3.222.346
4.284.877
4.413.423
4.499.121
4.584.819
1.601.650
1.649.699
1.681.732
1.713.765
K-4-16-ii
1.921.980
1.979.639
2.018.079
2.056.518
423
K-4-16-iii
2.569.209
2.646.286
2.697.670
2.749.054
424
K-4-17-i
1.281.320
1.319.759
1.345.386
1.371.012
425
K-4-17-ii
2.047.317
2.108.736
2.149.683
2.190.629
426
K-4-17-iii
2.724.770
2.806.513
2.861.008
2.915.504
427
K-4-18-i
1.398.645
1.440.604
1.468.577
1.496.550
428
K-4-18-ii
2.178.372
2.243.723
2.287.290
2.330.858
429
K-4-18-iii
2.532.943
2.608.931
2.659.590
2.710.249
430
L-1-20-i
14.359.452
14.790.235
15.077.424
15.364.613
431
L-1-20-ii
14.887.549
15.334.175
15.631.926
15.929.677
432
L-1-20-iii
22.886.416
23.573.008
24.030.736
24.488.465
433
L-1-30-i
6.041.174
6.222.409
6.343.232
6.464.056
434
L-1-30-ii
9.434.137
9.717.161
9.905.844
10.094.527
435
L-1-30-iii
9.950.071
10.248.573
10.447.574
10.646.576
436
L-1-40-i
2.629.770
2.708.663
2.761.258
2.813.854
437
L-1-40-ii
5.918.823
6.096.387
6.214.764
6.333.140
438
L-1-40-iii
9.904.358
10.201.488
10.399.576
10.597.663
439
L-1-50-i
4.315.124
4.444.578
4.530.880
4.617.183
440
L-1-50-ii
7.767.223
8.000.240
8.155.584
8.310.929
441
L-1-50-iii
9.391.672
9.673.422
9.861.256
10.049.089
442
L-4-10-i
1.921.980
1.979.639
2.018.079
2.056.518
443
L-4-10-ii
2.413.633
2.486.042
2.534.315
2.582.588

(SEDANG)
RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
- 989 No
Kode
INA-CBG
444
L-4-10-iii
445
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.967.522
5.116.548
5.215.898
5.315.248
L-4-11-i
1.990.779
2.050.502
2.090.318
2.130.133
446
L-4-11-ii
2.727.332
2.809.152
2.863.699
2.918.245
447
L-4-11-iii
7.396.183
7.618.069
7.765.993
7.913.916
448
L-4-12-i
1.965.249
2.024.207
2.063.512
2.102.817
449
L-4-12-ii
3.088.263
3.180.911
3.242.676
3.304.441
450
L-4-12-iii
5.001.331
5.151.371
5.251.398
5.351.424
451
L-4-13-i
1.321.134
1.360.768
1.387.190
1.413.613
452
L-4-13-ii
1.523.345
1.569.045
1.599.512
1.629.979
453
L-4-13-iii
2.285.136
2.353.690
2.399.393
2.445.096
454
L-4-14-i
1.281.320
1.319.759
1.345.386
1.371.012
455
L-4-14-ii
1.921.980
1.979.639
2.018.079
2.056.518
456
L-4-14-iii
3.290.928
3.389.656
3.455.474
3.521.293
457
M-1-01-i
6.246.933
6.434.341
6.559.280
6.684.219
458
M-1-01-ii
6.972.588
7.181.766
7.321.218
7.460.669
459
M-1-01-iii
9.794.597
10.088.435
10.284.327
10.480.219
460
M-1-02-i
3.990.937
4.110.665
4.190.484
4.270.303
461
M-1-02-ii
6.552.360
6.748.931
6.879.978
7.011.025
462
M-1-02-iii
11.866.024
12.222.004
12.459.325
12.696.645
463
M-1-03-i
10.723.090
11.044.783
11.259.244
11.473.706
464
M-1-03-ii
12.879.962
13.266.361
13.523.960
13.781.559
465
M-1-03-iii
13.376.885
13.778.191
14.045.729
14.313.266
466
M-1-04-i
2.632.702
2.711.683
2.764.337
2.816.991
467
M-1-04-ii
3.375.096
3.476.349
3.543.851
3.611.353
468
M-1-04-iii
4.223.297
4.349.995
4.434.461
4.518.927
469
M-1-05-i
4.101.244
4.224.281
4.306.306
4.388.331
470
M-1-05-ii
4.739.939
4.882.137
4.976.935
5.071.734
471
M-1-05-iii
8.073.406
8.315.608
8.477.077
8.638.545
472
M-1-07-i
5.018.931
5.169.499
5.269.878
5.370.256
473
M-1-07-ii
6.723.799
6.925.513
7.059.989
7.194.465
474
M-1-07-iii
13.697.017
14.107.927
14.381.867
14.655.808
475
M-1-10-i
2.829.412
2.914.295
2.970.883
3.027.471


TULANG WAJAH RINGAN
- 990 No
Kode
INA-CBG
476
M-1-10-ii
477
M-1-10-iii
478
M-1-20-i
479
M-1-20-ii
480
M-1-20-iii
481
M-1-30-i
482
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
10.514.023
10.829.444
11.039.724
11.250.005
13.114.540
13.507.976
13.770.267
14.032.558
2.799.020
2.882.990
2.938.971
2.994.951
3.991.981
4.111.740
4.191.580
4.271.419
7.766.088
7.999.071
8.154.393
8.309.714
1.674.232
1.724.459
1.757.944
1.791.428
M-1-30-ii
3.459.390
3.563.171
3.632.359
3.701.547
483
M-1-30-iii
PROSEDUR KAKI BERAT
5.160.680
5.315.500
5.418.714
5.521.927
484
M-1-40-i
1.875.428
1.931.690
1.969.199
2.006.708
485
M-1-40-ii
3.452.099
3.555.662
3.624.704
3.693.746
486
M-1-40-iii
6.041.174
6.222.409
6.343.232
6.464.056
487
M-1-50-i
2.240.419
2.307.632
2.352.440
2.397.248
488
M-1-50-ii
4.510.016
4.645.317
4.735.517
4.825.717
489
M-1-50-iii
6.904.198
7.111.324
7.249.408
7.387.492
490
M-1-60-i
1.690.809
1.741.534
1.775.350
1.809.166
491
M-1-60-ii
3.385.011
3.486.562
3.554.262
3.621.962
492
M-1-60-iii
5.891.117
6.067.851
6.185.673
6.303.496
493
M-1-70-i
2.265.005
2.332.955
2.378.255
2.423.555
494
M-1-70-ii
4.621.732
4.760.383
4.852.818
4.945.253
495
M-1-70-iii
7.450.790
7.674.313
7.823.329
7.972.345
496
M-1-80-i
1.824.981
1.879.730
1.916.230
1.952.730
497
M-1-80-ii
2.758.998
2.841.768
2.896.948
2.952.128
498
M-1-80-iii
6.351.928
6.542.486
6.669.524
6.796.563
499
M-4-10-i
1.281.320
1.319.759
1.345.386
1.371.012
500
M-4-10-ii
1.921.980
1.979.639
2.018.079
2.056.518
501
M-4-10-iii
FRAKTUR FEMUR BERAT
3.744.557
3.856.893
3.931.784
4.006.675
502
M-4-11-i
1.601.650
1.649.699
1.681.732
1.713.765
503
M-4-11-ii
3.509.173
3.614.448
3.684.631
3.754.815
504
M-4-11-iii
6.228.699
6.415.560
6.540.134
6.664.708
505
M-4-12-i
1.281.320
1.319.759
1.345.386
1.371.012
506
M-4-12-ii
2.331.360
2.401.301
2.447.928
2.494.555

TULANG WAJAH SEDANG
TULANG WAJAH BERAT

RINGAN
SEDANG
BERAT

SELAIN KAKI (BERAT)

PANGGUL RINGAN
PANGGUL SEDANG
PANGGUL BERAT
PELVIS RINGAN
PELVIS SEDANG
- 991 No
Kode
INA-CBG
507
M-4-12-iii
508
M-4-13-i
509
M-4-13-ii
510
M-4-13-iii
511
M-4-14-i
512
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.211.646
4.337.995
4.422.228
4.506.461
2.133.675
2.197.686
2.240.359
2.283.033
3.203.300
3.299.399
3.363.465
3.427.531
6.347.150
6.537.564
6.664.507
6.791.450
2.429.299
2.502.178
2.550.764
2.599.350
M-4-14-ii
3.001.030
3.091.060
3.151.081
3.211.102
513
M-4-14-iii
OSTEOMIELITIS BERAT
4.495.219
4.630.075
4.719.980
4.809.884
514
M-4-15-i
1.442.168
1.485.434
1.514.277
1.543.120
515
M-4-15-ii
1.923.013
1.980.703
2.019.164
2.057.624
516
M-4-15-iii
5.445.609
5.608.978
5.717.890
5.826.802
517
M-4-16-i
1.601.650
1.649.699
1.681.732
1.713.765
518
M-4-16-ii
2.562.640
2.639.519
2.690.772
2.742.024
519
M-4-16-iii
4.298.188
4.427.133
4.513.097
4.599.061
520
M-4-17-i
1.601.650
1.649.699
1.681.732
1.713.765
521
M-4-17-ii
2.242.310
2.309.579
2.354.425
2.399.271
522
M-4-17-iii
3.131.505
3.225.450
3.288.080
3.350.710
523
M-4-18-i
1.693.445
1.744.248
1.778.117
1.811.986
524
M-4-18-ii
2.562.640
2.639.519
2.690.772
2.742.024
525
M-4-18-iii
2.871.984
2.958.143
3.015.583
3.073.022
526
M-4-19-i
1.259.099
1.296.872
1.322.054
1.347.236
527
M-4-19-ii
2.120.726
2.184.348
2.226.763
2.269.177
528
M-4-19-iii
4.141.935
4.266.193
4.349.032
4.431.871
529
M-4-20-i
1.281.320
1.319.759
1.345.386
1.371.012
530
M-4-20-ii
1.921.980
1.979.639
2.018.079
2.056.518
531
M-4-20-iii
2.130.007
2.193.907
2.236.507
2.279.107
532
M-4-21-i
1.281.320
1.319.759
1.345.386
1.371.012
533
M-4-21-ii
1.601.650
1.649.699
1.681.732
1.713.765
534
M-4-21-iii
3.677.296
3.787.615
3.861.161
3.934.707
535
N-1-01-i
3.466.905
3.570.912
3.640.250
3.709.588
536
N-1-01-ii
4.688.911
4.829.578
4.923.356
5.017.134
537
N-1-01-iii
9.941.885
10.240.142
10.438.980
10.637.817

PELVIS BERAT

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
RINGAN
SEDANG
BERAT
ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
- 992 No
Kode
INA-CBG
538
N-1-11-i
539
N-1-11-ii
540
N-1-11-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
5.237.869
5.395.005
5.499.762
5.604.519
7.084.099
7.296.622
7.438.304
7.579.986
13.808.397
14.222.649
14.498.817
14.774.985
2.589.074
2.666.747
2.718.528
2.770.310
6.596.310
6.794.199
6.926.125
7.058.051
12.022.185
12.382.851
12.623.295
12.863.738
541
N-1-12-i
542
N-1-12-ii
543
N-1-12-iii
544
N-1-20-i
3.838.880
3.954.046
4.030.824
4.107.602
545
N-1-20-ii
7.611.134
7.839.468
7.991.691
8.143.913
546
N-1-20-iii
8.706.447
8.967.641
9.141.770
9.315.899
547
N-1-30-i
4.567.025
4.704.036
4.795.376
4.886.717
548
N-1-30-ii
6.940.164
7.148.369
7.287.173
7.425.976
549
N-1-30-iii
7.989.274
8.228.952
8.388.737
8.548.523
550
N-1-40-i
4.115.337
4.238.797
4.321.104
4.403.410
551
N-1-40-ii
5.578.486
5.745.840
5.857.410
5.968.980
552
N-1-40-iii
6.487.940
6.682.578
6.812.337
6.942.096
553
N-4-10-i
1.601.650
1.649.699
1.681.732
1.713.765
554
N-4-10-ii
2.348.680
2.419.140
2.466.114
2.513.088
555
N-4-10-iii
4.694.261
4.835.089
4.928.974
5.022.859
556
N-4-11-i
1.343.233
1.383.530
1.410.395
1.437.259
557
N-4-11-ii
2.270.032
2.338.132
2.383.533
2.428.934
558
N-4-11-iii
2.597.657
2.675.587
2.727.540
2.779.493
559
N-4-12-i
1.298.844
1.337.809
1.363.786
1.389.763
560
N-4-12-ii
1.921.980
1.979.639
2.018.079
2.056.518
561
N-4-12-iii
3.191.118
3.286.852
3.350.674
3.414.496
562
N-4-13-i
BATU URIN RINGAN
1.851.272
1.906.810
1.943.836
1.980.861
563
N-4-13-ii
BATU URIN SEDANG
2.231.938
2.298.896
2.343.535
2.388.173
564
N-4-13-iii
BATU URIN BERAT
5.496.650
5.661.550
5.771.483
5.881.416
1.109.860
1.143.156
1.165.353
1.187.551
1.709.045
1.760.317
1.794.498
1.828.679
2.771.527
2.854.673
2.910.103
2.965.534
565
N-4-14-i
566
N-4-14-ii
567
N-4-14-iii

URIN BAWAH RINGAN
URIN BAWAH SEDANG
URIN BAWAH BERAT
RINGAN
SEDANG
BERAT
GINJAL RINGAN
GINJAL SEDANG
GINJAL BERAT

(RINGAN)
(SEDANG)
(BERAT)
- 993 No
Kode
INA-CBG
568
N-4-15-i
569
N-4-15-ii
570
N-4-15-iii
571
N-4-16-i
572
N-4-16-ii
573
N-4-16-iii
574
O-6-10-i
575
O-6-10-ii
576
O-6-10-iii
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
584
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.803.206
1.857.303
1.893.367
1.929.431
2.474.560
2.548.797
2.598.288
2.647.779
2.823.920
2.908.637
2.965.116
3.021.594
1.810.993
1.865.323
1.901.543
1.937.762
2.562.640
2.639.519
2.690.772
2.742.024
5.388.850
5.550.515
5.658.292
5.766.069
2.252.540
2.320.116
2.365.167
2.410.218
2.500.663
2.575.683
2.625.696
2.675.709
3.081.664
3.174.114
3.235.747
3.297.380
1.422.058
1.464.720
1.493.161
1.521.603
2.316.950
2.386.459
2.432.798
2.479.137
3.926.512
4.044.307
4.122.837
4.201.368
1.572.685
1.619.865
1.651.319
1.682.773
1.888.791
1.945.454
1.983.230
2.021.006
2.372.995
2.444.185
2.491.645
2.539.104
1.162.905
1.197.792
1.221.050
1.244.308
O-6-13-ii
1.301.938
1.340.996
1.367.035
1.393.073
585
O-6-13-iii
1.619.132
1.667.706
1.700.089
1.732.471
586
P-8-01-i
32.194.235
33.160.062
33.803.947
34.447.832
587
P-8-01-ii
39.835.330
41.030.390
41.827.097
42.623.803
588
P-8-01-iii
46.755.511
48.158.176
49.093.286
50.028.397
589
P-8-02-i
42.716.550
43.998.047
44.852.378
45.706.709
590
P-8-02-ii
49.000.280
50.470.288
51.450.294
52.430.300
591
P-8-02-iii
55.986.323
57.665.913
58.785.640
59.905.366
592
P-8-03-i
2.157.562
2.222.289
2.265.440
2.308.591
593
P-8-03-ii
3.020.587
3.111.204
3.171.616
3.232.028
594
P-8-03-iii
4.758.109
4.900.853
4.996.015
5.091.177
595
P-8-04-i
21.101.609
21.734.657
22.156.689
22.578.721
596
P-8-04-ii
27.385.339
28.206.899
28.754.606
29.302.312

SALURAN URIN RINGAN
SALURAN URIN SEDANG
SALURAN URIN BERAT
RINGAN
SEDANG
BERAT
&KURET RINGAN
KURET SEDANG
KURET BERAT

- 994 No
Kode
INA-CBG
597
P-8-04-iii
598
P-8-05-i
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii
603
P-8-06-iii
604
P-8-07-i
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
614
P-8-11-ii
615
P-8-11-iii
616
P-8-12-i
617
P-8-12-ii
618
P-8-12-iii
619
P-8-13-i
620
P-8-13-ii
621
P-8-13-iii
622
P-8-14-i
623
P-8-14-ii
624
P-8-14-iii
Deskripsi (INA-CBG)
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
RINGAN
SEDANG
BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
39.263.683
40.441.593
41.226.867
42.012.140
11.474.371
11.818.602
12.048.089
12.277.577
16.263.374
16.751.275
17.076.542
17.401.810
23.961.898
24.680.755
25.159.993
25.639.231
1.726.050
1.777.831
1.812.352
1.846.873
4.756.372
4.899.063
4.994.190
5.089.318
8.847.394
9.112.816
9.289.764
9.466.712
3.049.308
3.140.787
3.201.773
3.262.759
8.468.998
8.723.068
8.892.448
9.061.828
11.219.323
11.555.902
11.780.289
12.004.675
2.397.206
2.469.122
2.517.066
2.565.010
3.403.171
3.505.266
3.573.330
3.641.393
4.804.232
4.948.359
5.044.444
5.140.529
1.487.224
1.531.840
1.561.585
1.591.329
2.154.460
2.219.094
2.262.183
2.305.272
4.229.840
4.356.735
4.441.332
4.525.929
1.801.500
1.855.545
1.891.575
1.927.605
8.917.530
9.185.056
9.363.407
9.541.757
9.104.354
9.377.484
9.559.571
9.741.659
1.976.097
2.035.380
2.074.902
2.114.424
3.072.488
3.164.663
3.226.112
3.287.562
3.624.886
3.733.633
3.806.130
3.878.628
1.021.354
1.051.994
1.072.421
1.092.848
1.890.007
1.946.707
1.984.507
2.022.307
2.826.707
2.911.508
2.968.042
3.024.577
1.866.119
1.922.103
1.959.425
1.996.747
3.810.087
3.924.390
4.000.591
4.076.793
4.179.651
4.305.041
4.388.634
4.472.227
- 995 No
Kode
INA-CBG
625
P-8-15-i
626
P-8-15-ii
627
P-8-15-iii
628
P-8-16-i
629
P-8-16-ii
630
P-8-16-iii
631
P-8-17-i
632
P-8-17-ii
633
P-8-17-iii
634
S-4-10-i
635
S-4-10-ii
636
S-4-10-iii
637
S-4-11-i
638
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.403.380
1.445.481
1.473.549
1.501.616
2.804.987
2.889.137
2.945.237
3.001.336
3.294.892
3.393.738
3.459.636
3.525.534
1.270.390
1.308.502
1.333.910
1.359.318
1.802.103
1.856.166
1.892.208
1.928.250
2.339.218
2.409.395
2.456.179
2.502.964
836.933
862.041
878.779
895.518
2.785.063
2.868.615
2.924.317
2.980.018
5.621.473
5.790.117
5.902.547
6.014.976
1.281.320
1.319.759
1.345.386
1.371.012
1.601.650
1.649.699
1.681.732
1.713.765
2.081.870
2.144.326
2.185.963
2.227.601
800.825
824.850
840.866
856.883
S-4-11-ii
1.281.320
1.319.759
1.345.386
1.371.012
639
S-4-11-iii
1.971.919
2.031.077
2.070.515
2.109.954
640
S-4-12-i
960.990
989.820
1.009.039
1.028.259
641
S-4-12-ii
1.281.320
1.319.759
1.345.386
1.371.012
642
S-4-12-iii
2.502.519
2.577.595
2.627.645
2.677.695
643
S-4-13-i
1.281.320
1.319.759
1.345.386
1.371.012
644
S-4-13-ii
2.265.086
2.333.039
2.378.340
2.423.642
645
S-4-13-iii
4.612.003
4.750.363
4.842.604
4.934.844
646
S-4-14-i
780.685
804.105
819.719
835.333
647
S-4-14-ii
1.658.436
1.708.189
1.741.358
1.774.526
648
S-4-14-iii
3.144.986
3.239.335
3.302.235
3.365.135
649
S-4-15-i
590.439
608.152
619.961
631.770
650
S-4-15-ii
1.114.359
1.147.790
1.170.077
1.192.365
651
S-4-15-iii
1.443.354
1.486.655
1.515.522
1.544.389
652
S-4-16-i
LUKA BAKAR RINGAN
2.242.310
2.309.579
2.354.425
2.399.271
653
S-4-16-ii
LUKA BAKAR SEDANG
3.468.144
3.572.188
3.641.551
3.710.914
654
S-4-16-iii
LUKA BAKAR BERAT
6.192.910
6.378.697
6.502.555
6.626.413
1.309.388
1.348.670
1.374.857
1.401.045
1.601.650
1.649.699
1.681.732
1.713.765
655
S-4-17-i
656
S-4-17-ii

ASPIRASI RINGAN
ASPIRASI SEDANG
ASPIRASI BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT

PASIEN RINGAN
PASIEN SEDANG
PASIEN BERAT

- 996 No
Kode
INA-CBG
657
S-4-17-iii
658
T-1-10-i
659
T-1-10-ii
660
T-1-10-iii
661
T-4-10-i
662
T-4-10-ii
663
T-4-10-iii
664
T-4-11-i
665
T-4-11-ii
666
T-4-11-iii
667
T-4-12-i
668
T-4-12-ii
669
T-4-12-iii
670
U-1-10-i
671
U-1-10-ii
672
U-1-10-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.611.806
2.690.160
2.742.396
2.794.632
1.351.650
1.392.199
1.419.232
1.446.265
1.815.174
1.869.629
1.905.933
1.942.236
3.302.393
3.401.465
3.467.513
3.533.561
539.889
556.086
566.884
577.681
1.028.909
1.059.776
1.080.355
1.100.933
1.495.755
1.540.627
1.570.542
1.600.457
584.713
602.254
613.948
625.642
920.171
947.776
966.180
984.583
1.482.125
1.526.588
1.556.231
1.585.873
1.121.155
1.154.790
1.177.213
1.199.636
1.694.564
1.745.401
1.779.292
1.813.183
2.636.132
2.715.216
2.767.939
2.820.662
1.193.367
1.229.168
1.253.035
1.276.902
2.435.138
2.508.192
2.556.895
2.605.598
10.515.418
10.830.880
11.041.188
11.251.497
5.178.149
5.333.493
5.437.056
5.540.619
6.904.198
7.111.324
7.249.408
7.387.492
12.703.173
13.084.269
13.338.332
13.592.395

DOKTER RINGAN
DOKTER SEDANG
DOKTER BERAT

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
673
U-1-11-i
674
U-1-11-ii
675
U-1-11-iii
676
U-1-12-i
3.465.462
3.569.426
3.638.735
3.708.044
677
U-1-12-ii
7.767.223
8.000.240
8.155.584
8.310.929
678
U-1-12-iii
10.085.886
10.388.463
10.590.181
10.791.899
679
U-1-13-i
3.452.099
3.555.662
3.624.704
3.693.746
680
U-1-13-ii
4.265.437
4.393.400
4.478.708
4.564.017
681
U-1-13-iii
7.510.474
7.735.789
7.885.998
8.036.208
2.085.964
2.148.543
2.190.263
2.231.982
2.559.898
2.636.695
2.687.893
2.739.091
3.033.551
3.124.557
3.185.228
3.245.899

682
U-1-14-i
683
U-1-14-ii
684
U-1-14-iii
685
U-1-15-i
1.225.166
1.261.921
1.286.425
1.310.928
686
U-1-15-ii
1.740.876
1.793.102
1.827.920
1.862.737
687
U-1-15-iii
3.430.466
3.533.380
3.601.989
3.670.599
- 997 No
Kode
INA-CBG
688
U-1-20-i
689
U-1-20-ii
690
U-1-20-iii
691
U-1-30-i
692
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.168.972
3.264.041
3.327.420
3.390.800
5.640.770
5.809.993
5.922.808
6.035.624
12.707.125
13.088.339
13.342.481
13.596.624
2.718.425
2.799.978
2.854.346
2.908.715
U-1-30-ii
3.669.874
3.779.970
3.853.368
3.926.765
693
U-1-30-iii
6.904.198
7.111.324
7.249.408
7.387.492
694
U-4-10-i
2.530.400
2.606.312
2.656.920
2.707.528
695
U-4-10-ii
6.343.181
6.533.476
6.660.340
6.787.204
696
U-4-10-iii
9.253.320
9.530.919
9.715.986
9.901.052
697
U-4-11-i
1.281.320
1.319.759
1.345.386
1.371.012
698
U-4-11-ii
1.921.980
1.979.639
2.018.079
2.056.518
699
U-4-11-iii
2.910.961
2.998.290
3.056.509
3.114.728
700
U-4-12-i
1.281.320
1.319.759
1.345.386
1.371.012
701
U-4-12-ii
1.635.825
1.684.900
1.717.617
1.750.333
702
U-4-12-iii
2.600.888
2.678.915
2.730.933
2.782.950
703
U-4-13-i
1.281.320
1.319.759
1.345.386
1.371.012
704
U-4-13-ii
1.463.431
1.507.334
1.536.603
1.565.871
705
U-4-13-iii
1.819.693
1.874.284
1.910.678
1.947.072
706
U-4-14-i
1.601.650
1.649.699
1.681.732
1.713.765
707
U-4-14-ii
1.921.980
1.979.639
2.018.079
2.056.518
708
U-4-14-iii
3.219.650
3.316.239
3.380.632
3.445.025
709
U-4-15-i
1.281.320
1.319.759
1.345.386
1.371.012
710
U-4-15-ii
1.601.650
1.649.699
1.681.732
1.713.765
711
U-4-15-iii
2.242.744
2.310.027
2.354.882
2.399.736
712
V-1-10-i
3.745.723
3.858.094
3.933.009
4.007.923
713
V-1-10-ii
4.315.124
4.444.578
4.530.880
4.617.183
714
V-1-10-iii
8.198.736
8.444.698
8.608.672
8.772.647
715
V-1-11-i
4.315.124
4.444.578
4.530.880
4.617.183
716
V-1-11-ii
4.815.751
4.960.223
5.056.538
5.152.853
717
V-1-11-iii
7.131.390
7.345.331
7.487.959
7.630.587
2.552.222
2.628.788
2.679.833
2.730.877
9.569.408
9.856.491
10.047.879
10.239.267
10.762.055
11.084.916
11.300.157
11.515.398
718
V-1-12-i
719
V-1-12-ii
720
V-1-12-iii


DAN TELINGA RINGAN
DAN TELINGA SEDANG
DAN TELINGA BERAT


KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

- 998 No
Kode
INA-CBG
721
V-1-13-i
722
V-1-13-ii
723
V-1-13-iii
724
V-1-14-i
725
V-1-14-ii
726
V-1-14-iii
727
V-1-15-i
728
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.868.341
3.984.391
4.061.758
4.139.125
7.350.957
7.571.486
7.718.505
7.865.524
10.356.298
10.666.987
10.874.113
11.081.239
4.663.330
4.803.229
4.896.496
4.989.763
6.782.413
6.985.886
7.121.534
7.257.182
9.219.704
9.496.295
9.680.690
9.865.084
2.198.500
2.264.455
2.308.425
2.352.395
V-1-15-ii
4.040.421
4.161.633
4.242.442
4.323.250
729
V-1-15-iii
6.722.404
6.924.076
7.058.524
7.192.972
730
V-4-10-i
3.540.140
3.646.345
3.717.147
3.787.950
731
V-4-10-ii
4.572.514
4.709.690
4.801.140
4.892.590
732
V-4-10-iii
8.738.877
9.001.044
9.175.821
9.350.599
733
V-4-11-i
1.800.294
1.854.303
1.890.309
1.926.315
734
V-4-11-ii
2.630.517
2.709.433
2.762.043
2.814.653
735
V-4-11-iii
4.340.179
4.470.384
4.557.188
4.643.992
736
W-1-01-i
5.293.746
5.452.558
5.558.433
5.664.308
737
W-1-01-ii
6.376.066
6.567.348
6.694.869
6.822.390
738
W-1-01-iii
14.083.463
14.505.967
14.787.636
15.069.305
739
W-1-10-i
1.474.302
1.518.531
1.548.017
1.577.503
740
W-1-10-ii
2.751.289
2.833.828
2.888.854
2.943.879
741
W-1-10-iii
4.500.236
4.635.243
4.725.248
4.815.253
742
W-1-11-i
1.531.309
1.577.249
1.607.875
1.638.501
743
W-1-11-ii
2.953.324
3.041.924
3.100.990
3.160.057
744
W-1-11-iii
5.178.149
5.333.493
5.437.056
5.540.619
745
W-1-12-i
1.391.425
1.433.167
1.460.996
1.488.824
746
W-1-12-ii
1.582.023
1.629.484
1.661.124
1.692.765
747
W-1-12-iii
2.430.187
2.503.093
2.551.696
2.600.300
748
W-1-13-i
1.512.259
1.557.627
1.587.872
1.618.117
749
W-1-13-ii
1.641.878
1.691.134
1.723.972
1.756.809
750
W-1-13-iii
2.205.345
2.271.505
2.315.612
2.359.719
751
W-1-20-i
4.512.467
4.647.841
4.738.090
4.828.339
752
W-1-20-ii
6.347.462
6.537.885
6.664.835
6.791.784

NON KOMPLEK (BERAT)

RINGAN
SEDANG
BERAT

SERVIK RINGAN
SERVIK SEDANG
SERVIK BERAT
ENDOSKOP RINGAN
ENDOSKOP SEDANG
ENDOSKOP BERAT
- 999 No
Kode
INA-CBG
753
W-1-20-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
7.767.223
8.000.240
8.155.584
8.310.929
2.463.354
2.537.255
2.586.522
2.635.789
3.929.178
4.047.053
4.125.637
4.204.220
10.448.650
10.762.110
10.971.083
11.180.056
754
W-1-30-i
755
W-1-30-ii
756
W-1-30-iii
757
W-4-10-i
1.837.045
1.892.157
1.928.897
1.965.638
758
W-4-10-ii
2.482.972
2.557.462
2.607.121
2.656.780
759
W-4-10-iii
5.125.279
5.279.038
5.381.543
5.484.049
760
W-4-11-i
1.601.650
1.649.699
1.681.732
1.713.765
761
W-4-11-ii
2.562.640
2.639.519
2.690.772
2.742.024
762
W-4-11-iii
3.114.367
3.207.798
3.270.085
3.332.372
1.281.320
1.319.759
1.345.386
1.371.012
1.782.983
1.836.472
1.872.132
1.907.792
2.151.090
2.215.622
2.258.644
2.301.666

763
W-4-12-i
764
W-4-12-ii
765
W-4-12-iii
766
W-4-13-i
ABORTUS RINGAN
702.691
723.772
737.825
751.879
767
W-4-13-ii
ABORTUS SEDANG
960.990
989.820
1.009.039
1.028.259
768
W-4-13-iii
ABORTUS BERAT
1.281.320
1.319.759
1.345.386
1.371.012
769
W-4-14-i
960.990
989.820
1.009.039
1.028.259
770
W-4-14-ii
1.281.320
1.319.759
1.345.386
1.371.012
771
W-4-14-iii
1.555.251
1.601.909
1.633.014
1.664.119
772
W-4-15-i
877.588
903.916
921.468
939.020
773
W-4-15-ii
976.046
1.005.327
1.024.848
1.044.369
774
W-4-15-iii
1.306.707
1.345.908
1.372.042
1.398.176
775
W-4-16-i
960.990
989.820
1.009.039
1.028.259
776
W-4-16-ii
1.394.932
1.436.780
1.464.679
1.492.578
777
W-4-16-iii
1.777.811
1.831.146
1.866.702
1.902.258
778
W-4-17-i
859.563
885.350
902.541
919.732
779
W-4-17-ii
1.281.320
1.319.759
1.345.386
1.371.012
780
W-4-17-iii
2.424.002
2.496.722
2.545.202
2.593.682
781
Z-4-10-i
REHABILITASI RINGAN
2.198.593
2.264.551
2.308.523
2.352.495
782
Z-4-10-ii
REHABILITASI SEDANG
2.918.315
3.005.864
3.064.231
3.122.597
783
Z-4-10-iii
REHABILITASI BERAT
4.145.745
4.270.117
4.353.032
4.435.947
784
Z-4-11-i
2.101.701
2.164.752
2.206.787
2.248.821
785
Z-4-11-ii
2.529.984
2.605.884
2.656.483
2.707.083
786
Z-4-11-iii
3.955.282
4.073.940
4.153.046
4.232.152
- 1000 No
Kode
INA-CBG
787
Z-4-12-i
788
Z-4-12-ii
789
Z-4-12-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
960.990
989.820
1.009.039
1.028.259
2.144.253
2.208.581
2.251.466
2.294.351
2.725.006
2.806.757
2.861.257
2.915.757
- 1001 b. RawatJalan
No
Kode
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
749.845
772.341
787.338
802.335
972.667
1.001.847
1.021.300
1.040.753
1.808.802
1.863.066
1.899.242
1.935.418
1.494.799
1.539.643
1.569.539
1.599.435
1.248.776
1.286.239
1.311.215
1.336.190
437.826
450.961
459.718
468.474
976.295
1.005.584
1.025.110
1.044.636
B-3-12-0

200.597
206.615
210.627
214.638
C-3-10-0
547.199
563.615
574.559
585.503
10
C-3-11-0

KANDUNG KEMIH
865.416
891.379
908.687
925.995
11
C-3-12-0
196.188
202.074
205.997
209.921
190.512
196.227
200.038
203.848
1.621.832
1.670.487
1.702.924
1.735.360
1.486.474
1.531.068
1.560.797
1.590.527

LAPAROSKOPI
PANKREAS
LAPAROSKOPI
EMPEDU

OVARIUM
GASTROINTESTINAL
GINJAL ATAU PROSTAT
12
C-3-13-0
13
C-3-14-0
14
C-3-15-0
15
C-3-16-0
337.096
347.209
353.951
360.693
16
C-3-17-0

LEHER
223.620
230.328
234.801
239.273
17
C-3-18-0
99.143
102.118
104.101
106.083
18
C-3-19-0

MYELOMA ATAU TESTIS
140.209
144.415
147.219
150.024
19
C-3-20-0
2.792.265
2.876.033
2.931.878
2.987.724
20
C-3-21-0
160.003
164.804
168.004
171.204
21
C-3-22-0
702.500
723.575
737.625
751.675
22
C-3-23-0
113.790
117.203
119.479
121.755
23
D-2-10-0

TULANG
964.042
992.964
1.012.244
1.031.525
24
D-2-11-0
1.207.146
1.243.360
1.267.503
1.291.646
1.012.453
1.042.827
1.063.076
1.083.325
222.203
228.869
233.313
237.757
160.947
165.776
168.995
172.213
417.865
430.401
438.758
447.116
247.874
255.311
260.268
265.226
179.700
185.092
188.686
192.280
179.700
185.092
188.686
192.280
25
D-2-21-0
26
D-2-22-0
27
D-3-10-0
28
D-3-11-0
29
E-2-10-0
30
E-2-21-0
31
E-2-22-0
PROSEDUR LIMPA
TYMUS
TYMUS
TULANG
PEMBENTUK DARAH
PARATIROID
THYROGLOSSAL
- 1002 No
Kode
INA-CBG
32
E-3-10-0
33
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

ENDOKRIN
208.980
215.249
219.429
223.609
F-3-10-0
TERAPI SHOCK
291.520
300.266
306.096
311.927
34
F-5-10-0
357.207
367.923
375.067
382.211
35
F-5-11-0
TERAPI KELOMPOK
235.545
242.611
247.322
252.033
36
F-5-12-0
301.420
310.463
316.491
322.519
37
F-5-13-0
255.283
262.941
268.047
273.152
38
F-5-14-0
171.261
176.398
179.824
183.249
39
F-5-15-0
160.664
165.484
168.698
171.911
40
F-5-16-0
167.347
172.368
175.715
179.062
41
G-2-10-0
140.919
145.147
147.965
150.784
42
G-2-11-0
1.221.549
1.258.195
1.282.626
1.307.057
43
G-2-12-0

EKSTRAKRANIAL
1.770.325
1.823.434
1.858.841
1.894.247
44
G-2-13-0
434.300
447.329
456.015
464.701
45
G-2-21-0
792.090
815.853
831.695
847.537
46
G-2-22-0
718.889
740.456
754.834
769.211
47
G-2-31-0
1.186.230
1.221.817
1.245.541
1.269.266
48
G-2-32-0
608.060
626.302
638.463
650.625
49
G-3-10-0
241.343
248.583
253.410
258.237
50
G-3-11-0
321.423
331.065
337.494
343.922
51
G-3-12-0
526.657
542.456
552.989
563.522
52
G-3-13-0
526.717
542.518
553.052
563.587
53
H-2-21-0
691.237
711.974
725.799
739.624
54
H-2-22-0
179.700
185.092
188.686
192.280
55
H-2-23-0
179.700
185.092
188.686
192.280
56
H-2-31-0
1.144.977
1.179.326
1.202.226
1.225.126
57
H-2-32-0
119.165
122.740
125.124
127.507
58
H-2-33-0
179.700
185.092
188.686
192.280
59
H-2-34-0
513.665
529.075
539.348
549.621
60
H-2-35-0
169.264
174.342
177.727
181.113
61
H-2-36-0
913.648
941.058
959.331
977.604
62
H-2-37-0

972.619
1.001.797
1.021.250
1.040.702
63
H-3-10-0
338.400
348.552
355.320
362.088
64
H-3-11-0
177.961
183.300
186.859
190.418

AKUT
MENTAL
PROSEDUR KRANIOTOMI

MATA
MATA
MATA
MATA
MATA
- 1003 No
Kode
INA-CBG
65
H-3-12-0
66
H-3-13-0
67
I-2-11-0
68
I-2-12-0
69
I-2-13-0
70
I-2-14-0
71
I-2-15-0
Deskripsi (INA-CBG)
MATA
TORASIK
ABDOMEN
PENGGANTIAN ALAT
DARAH VENA
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
185.800
191.374
195.090
198.806
180.401
185.813
189.421
193.029
2.080.408
2.142.820
2.184.428
2.226.036
1.462.754
1.506.636
1.535.891
1.565.147
1.859.072
1.914.844
1.952.026
1.989.207
3.290.162
3.388.866
3.454.670
3.520.473
197.864
203.800
207.757
211.714
2.078.153
2.140.498
2.182.061
2.223.624
685.107
705.661
719.363
733.065
72
I-2-16-0
73
I-2-17-0
74
I-2-21-0
1.604.039
1.652.160
1.684.241
1.716.322
75
I-2-22-0
1.510.484
1.555.798
1.586.008
1.616.217
76
I-2-23-0
309.116
318.389
324.572
330.754
77
I-2-31-0
2.404.099
2.476.222
2.524.304
2.572.386
78
I-2-32-0
3.143.712
3.238.024
3.300.898
3.363.772
79
I-2-41-0
2.107.898
2.171.135
2.213.293
2.255.451
80
I-2-42-0

LAIN
2.450.780
2.524.303
2.573.319
2.622.335
81
I-3-10-0
PROSEDUR RESUSITASI
311.105
320.438
326.660
332.882
82
I-3-11-0
164.200
169.126
172.410
175.694
83
I-3-12-0
954.271
982.899
1.001.984
1.021.070
84
I-3-13-0
313.419
322.822
329.090
335.359
85
I-3-14-0
200.891
206.918
210.936
214.954
177.961
183.300
186.859
190.418
1.101.820
1.134.875
1.156.911
1.178.948
177.613
182.942
186.494
190.046
895.060
921.912
939.813
957.714
1.160.973
1.195.802
1.219.021
1.242.241

PACU JANTUNG

KARDIOVASKULAR
PERNAFASAN
PENDEK
86
I-3-15-0
87
J-2-10-0
88
J-2-21-0
89
J-2-22-0
90
J-2-31-0
PROSEDUR
91
J-2-32-0
863.956
889.875
907.154
924.433
92
J-3-10-0
179.700
185.092
188.686
192.280
93
J-3-11-0

PADA DADA
507.802
523.036
533.192
543.348
94
J-3-12-0
196.188
202.074
205.997
209.921
95
J-3-13-0
288.740
297.402
303.177
308.952
96
J-3-14-0
306.529
315.725
321.855
327.986
- 1004 No
Kode
INA-CBG
97
J-3-15-0
98
J-3-16-0
99
J-3-17-0
100
K-2-10-0
101
K-2-11-0
102
K-2-12-0

103
K-2-13-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
268.801
276.865
282.241
287.617
306.529
315.725
321.855
327.986
179.700
185.092
188.686
192.280
517.240
532.757
543.102
553.446
1.104.517
1.137.653
1.159.743
1.181.834
847.860
873.295
890.253
907.210
1.379.937
1.421.336
1.448.934
1.476.533
179.700
185.092
188.686
192.280
179.700
185.092
188.686
192.280
2.309.579
2.378.867
2.425.058
2.471.250
776.594
799.892
815.424
830.956
179.700
185.092
188.686
192.280

PERNAFASAN
KECIL

FEMORALIS
USUS BESAR
ATAS
ATAS
104
K-2-14-0
105
K-2-21-0
106
K-2-22-0
107
K-2-31-0
108
K-2-32-0
109
K-2-41-0
855.435
881.098
898.206
915.315
110
K-2-42-0

244.408
251.740
256.629
261.517
111
K-2-51-0
566.863
583.869
595.206
606.543
112
K-2-52-0
309.116
318.389
324.572
330.754
113
K-2-53-0
179.700
185.092
188.686
192.280
114
K-3-10-0

GASTROINTESTINAL
341.958
352.217
359.056
365.895
115
K-3-11-0
205.584
211.751
215.863
219.974
116
K-3-12-0
208.488
214.742
218.912
223.082
117
K-3-13-0
179.700
185.092
188.686
192.280
481.601
496.049
505.681
515.313
232.572
239.549
244.201
248.852
308.173
317.418
323.581
329.745
1.059.509
1.091.294
1.112.484
1.133.674
679.138
699.512
713.095
726.677
306.529
315.725
321.855
327.986
309.116
318.389
324.572
330.754

GASTROINTESTINAL
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
118
K-3-14-0
119
K-3-15-0
120
K-3-16-0
121
L-2-21-0
122
L-2-22-0
123
L-2-31-0
124
L-2-32-0
125
L-2-41-0
925.611
953.379
971.892
990.404
126
L-2-42-0

207.600
213.828
217.980
222.132
127
L-2-51-0
1.385.785
1.427.358
1.455.074
1.482.790
L-2-52-0

1.060.171
1.091.976
1.113.180
1.134.383
128
- 1005 No
Kode
INA-CBG
129
L-2-53-0
130
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

179.700
185.092
188.686
192.280
L-3-10-0
244.408
251.740
256.629
261.517
131
L-3-11-0
237.337
244.457
249.204
253.951
132
L-3-12-0
180.755
186.178
189.793
193.408
133
M-2-10-0
1.417.759
1.460.291
1.488.647
1.517.002
134
M-2-21-0
1.269.701
1.307.792
1.333.186
1.358.580
135
M-2-22-0
309.116
318.389
324.572
330.754
136
M-2-31-0
PROSEDUR BUNION
771.216
794.352
809.777
825.201
137
M-2-32-0
244.408
251.740
256.629
261.517
138
M-2-41-0

TULANG
244.408
251.740
256.629
261.517
139
M-2-42-0
84.230
86.757
88.441
90.126
140
M-2-51-0
179.700
185.092
188.686
192.280
141
M-2-52-0
179.700
185.092
188.686
192.280
142
M-2-61-0
PROSEDUR ARTROSKOPI
880.806
907.230
924.847
942.463
143
M-2-62-0
179.700
185.092
188.686
192.280
885.571
912.138
929.850
947.561
1.207.736
1.243.968
1.268.123
1.292.277
179.700
185.092
188.686
192.280
891.627
918.375
936.208
954.040
860.458
886.271
903.481
920.690

DAN WAJAH
PAHA
PAHA

TULANG
WAJAH
WAJAH
BAWAH
BAWAH
144
M-2-63-0
145
M-2-64-0
146
M-2-65-0
147
M-2-71-0
148
M-2-72-0
149
M-2-81-0
1.283.126
1.321.619
1.347.282
1.372.944
150
M-2-82-0
932.108
960.072
978.714
997.356
151
M-2-83-0
179.700
185.092
188.686
192.280
152
M-2-84-0
179.700
185.092
188.686
192.280
153
M-3-10-0
512.900
528.287
538.545
548.803
154
M-3-11-0
284.372
292.903
298.590
304.278
155
M-3-12-0
643.085
662.377
675.239
688.101
156
M-3-13-0
209.663
215.953
220.146
224.339
157
M-3-14-0

TERTUTUP
358.350
369.100
376.267
383.434
158
M-3-15-0
157.875
162.611
165.769
168.926
159
M-3-16-0

179.700
185.092
188.686
192.280
160
M-3-17-0
196.188
202.074
205.997
209.921
161
N-2-11-0
2.374.020
2.445.241
2.492.721
2.540.201

PERGELANGAN TANGAN
PERGELANGAN TANGAN
MUSKULOSKELETAL
SKELETAL
- 1006 No
Kode
INA-CBG
162
N-2-12-0
163
N-2-21-0
164
N-2-22-0
165
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.373.347
1.414.548
1.442.014
1.469.481
1.366.108
1.407.091
1.434.413
1.461.736
309.116
318.389
324.572
330.754
N-2-23-0
309.116
318.389
324.572
330.754
166
N-2-24-0
998.959
1.028.928
1.048.907
1.068.886
167
N-2-31-0
840.961
866.190
883.010
899.829
168
N-2-32-0
309.116
318.389
324.572
330.754
169
N-2-41-0
309.116
318.389
324.572
330.754
170
N-2-42-0
522.774
538.457
548.913
559.368
171
N-3-10-0
309.116
318.389
324.572
330.754
172
N-3-11-0
358.155
368.900
376.063
383.226
173
N-3-12-0
276.762
285.065
290.600
296.135
174
N-3-13-0
309.116
318.389
324.572
330.754
175
N-3-14-0
265.977
273.957
279.276
284.596
176
N-3-15-0
682.033
702.494
716.135
729.775
177
O-7-10-0
113.870
117.286
119.564
121.841
178
O-7-11-0
627.113
645.926
658.469
671.011
179
O-7-12-0
228.353
235.204
239.771
244.338
180
O-7-13-0
126.909
130.716
133.254
135.792
181
P-9-10-0
169.264
174.342
177.727
181.113
182
P-9-11-0
169.264
174.342
177.727
181.113
183
P-9-12-0
169.264
174.342
177.727
181.113
184
P-9-13-0
169.264
174.342
177.727
181.113
185
P-9-14-0
169.264
174.342
177.727
181.113
186
P-9-15-0
107.893
111.129
113.287
115.445
187
P-9-16-0
169.264
174.342
177.727
181.113
188
P-9-17-0
168.536
173.592
176.963
180.334
189
Q-5-10-0
220.605
227.223
231.635
236.048
190
Q-5-11-0
165.338
170.298
173.604
176.911
191
Q-5-12-0
GIGI
145.724
150.096
153.010
155.925
192
Q-5-13-0
MEDICAL CHECK-UP
110.744
114.066
116.281
118.496
193
Q-5-14-0
121.855
125.510
127.947
130.384


DAN URETHRA
DAN URETHRA
TRANSURETHRA
TRANSURETHRA
SALURAN KEMIH
KEMIH
KEMIH
PROSEDUR DIALISIS
CAESAR
VAGINAL/JALAN LAHIR

ASPIRASI
- 1007 No
Kode
INA-CBG
194
Q-5-15-0
195
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
83.799
86.313
87.989
89.665
Q-5-16-0
VAKSINASI
94.713
97.554
99.448
101.342
196
Q-5-17-0
PASANG INFUS
81.924
84.382
86.020
87.659
197
Q-5-18-0
154.206
158.833
161.917
165.001
198
Q-5-19-0
172.394
177.565
181.013
184.461
199
Q-5-20-0
ABORSI MENGANCAM
115.550
119.016
121.327
123.638
200
Q-5-21-0
ABORSI
113.976
117.395
119.675
121.954
201
Q-5-22-0
121.855
125.510
127.947
130.384
202
Q-5-23-0
149.182
153.658
156.641
159.625
203
Q-5-24-0
101.889
104.946
106.984
109.022
204
Q-5-25-0
158.894
163.661
166.839
170.017
205
Q-5-26-0
BRONKIAL AKUT
224.904
231.651
236.149
240.647
206
Q-5-27-0
160.053
164.854
168.055
171.256
207
Q-5-28-0
129.879
133.775
136.372
138.970
208
Q-5-29-0

JANTUNG LAIN-LAIN
367.708
378.739
386.093
393.447
209
Q-5-30-0
426.133
438.917
447.440
455.963
210
Q-5-31-0
FRAKTUR
152.027
156.588
159.629
162.669
211
Q-5-32-0
SALURAN KEMIH AKUT
176.082
181.364
184.886
188.408
212
Q-5-33-0
HEMATOLOGI AKUT
184.357
189.888
193.575
197.262
213
Q-5-34-0
INFEKSI VIRUS HIV
261.892
269.749
274.987
280.225
214
Q-5-35-0
INFEKSI AKUT
296.979
305.888
311.828
317.767
215
Q-5-36-0
345.851
356.226
363.143
370.060
216
Q-5-37-0

SHOCK
176.402
181.694
185.222
188.750
217
Q-5-38-0
PARU AKUT
235.237
242.294
246.999
251.704
218
Q-5-39-0
150.534
155.051
158.061
161.072
219
Q-5-40-0
147.698
152.129
155.083
158.037
220
Q-5-41-0
204.468
210.602
214.691
218.780
221
Q-5-42-0
160.311
165.120
168.326
171.532
222
Q-5-43-0
230.857
237.782
242.400
247.017
223
Q-5-44-0
188.411
194.063
197.832
201.600
224
T-2-10-0

TERAPI DETOKSIKASI
97.726
100.657
102.612
104.566
225
U-2-10-0
1.304.259
1.343.387
1.369.472
1.395.557
226
U-2-11-0

LEHER
1.550.257
1.596.765
1.627.770
1.658.775
227
U-2-12-0
170.569
175.686
179.097
182.509
- 1008 No
Kode
INA-CBG
228
U-2-13-0
229
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
223.620
230.328
234.801
239.273
U-2-14-0
415.384
427.846
436.153
444.461
230
U-2-15-0
236.012
243.093
247.813
252.533
231
U-2-21-0
274.917
283.165
288.663
294.162
232
U-2-22-0
531.163
547.097
557.721
568.344
233
U-2-23-0
695.995
716.874
730.794
744.714
234
U-2-24-0
586.572
604.169
615.901
627.632
235
U-2-25-0
223.620
230.328
234.801
239.273
236
U-2-31-0
179.700
185.092
188.686
192.280
237
U-2-32-0
223.620
230.328
234.801
239.273
238
U-3-10-0
213.792
220.206
224.482
228.758
239
U-3-11-0
226.981
233.790
238.330
242.869
240
U-3-12-0
100.371
103.382
105.389
107.397
241
U-3-13-0
220.622
227.241
231.654
236.066
242
U-3-14-0
202.707
208.788
212.842
216.896
243
U-3-15-0
176.778
182.082
185.617
189.153
244
U-3-16-0
PROSEDUR PADA GIGI
199.374
205.355
209.342
213.330
245
V-2-10-0

PROSTAT
1.945.121
2.003.474
2.042.377
2.081.279
246
V-2-11-0
219.360
225.941
230.328
234.715
700.009
721.010
735.010
749.010
309.116
318.389
324.572
330.754
309.116
318.389
324.572
330.754

(RHINOPLASTY)

RONGGA HIDUNG
TENGGOROKAN
PROSEDUR PADA PENIS

SKROTUM
SKROTUM
TRANSURETHRAL
247
V-2-12-0
248
V-2-13-0
249
V-2-14-0
250
V-2-15-0
SIRKUMSISI/SUNAT
169.264
174.342
177.727
181.113
251
V-3-10-0
353.012
363.602
370.662
377.723
252
V-3-11-0
746.803
769.207
784.143
799.079
253
V-3-12-0
431.149
444.083
452.706
461.329
254
W-2-10-0
157.875
162.611
165.769
168.926
255
W-2-11-0
403.469
415.573
423.643
431.712
256
W-2-12-0
746.803
769.207
784.143
799.079
257
W-2-13-0
119.774
123.367
125.763
128.158
258
W-2-21-0
1.501.273
1.546.311
1.576.336
1.606.362
259
W-2-22-0
157.875
162.611
165.769
168.926

PROSEDUR ABORSI
RAHIM & LEHER RAHIM
TERHALANG/TERGANGGU
TERHALANG/TERGANGGU
PANGGUL TERBUKA
PANGGUL TERBUKA
- 1009 No
Kode
INA-CBG
260
W-2-23-0
Deskripsi (INA-CBG)
JALAN LAHIR
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
526.836
542.641
553.178
563.715
1.729.443
1.781.326
1.815.915
1.850.504
1.212.937
1.249.325
1.273.584
1.297.842
261
W-2-31-0
262
W-2-32-0
263
W-2-33-0
515.514
530.980
541.290
551.600
264
W-2-34-0
175.335
180.595
184.102
187.609
265
W-3-10-0
426.133
438.917
447.440
455.962
266
W-3-11-0
340.638
350.858
357.670
364.483
267
W-3-12-0
157.875
162.611
165.769
168.926
268
Z-3-10-0
1.787.354
1.840.975
1.876.722
1.912.469
269
Z-3-11-0

EMPEDU
1.366.108
1.407.091
1.434.413
1.461.736
270
Z-3-12-0
228.107
234.950
239.512
244.074
271
Z-3-13-0

LAIN-LAIN
1.391.971
1.433.731
1.461.570
1.489.409
272
Z-3-14-0
DIAGNOSTIK TIDUR
275.236
283.493
288.998
294.502
273
Z-3-15-0
179.700
185.092
188.686
192.280
274
Z-3-16-0

(MRI)
576.784
594.088
605.623
617.159
275
Z-3-17-0
PENGOBATAN NUKLIR
242.146
249.411
254.254
259.097
276
Z-3-18-0
CT-SCAN KEPALA
233.303
240.302
244.969
249.635
277
Z-3-19-0
CT SCAN LAIN-LAIN
242.823
250.108
254.965
259.821
278
Z-3-20-0
165.150
170.105
173.408
176.711
279
Z-3-21-0
157.875
162.611
165.769
168.926
280
Z-3-22-0
177.990
183.329
186.889
190.449
281
Z-3-23-0
185.392
190.953
194.661
198.369
282
Z-3-24-0
364.258
375.186
382.471
389.756
283
Z-3-25-0
162.240
167.107
170.352
173.597
284
Z-3-26-0
183.363
188.864
192.531
196.199
285
Z-3-27-0
PERAWATAN LUKA
175.062
180.314
183.815
187.316
286
Z-3-28-0
IMAGING PAYUDARA
179.700
185.092
188.686
192.280
287
Z-3-29-0
IMAGING LAIN-LAIN
517.929
533.467
543.826
554.184
288
Z-3-30-0
FOTOTERAPI
87.407
90.029
91.778
93.526
- 1010 5. RUMAH SAKIT PARUKELAS D

a. RawatInap
No
Kode
INA-CBG
A-4-10-i
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
SEPTIKEMIA RINGAN
1.817.415
1.871.937
1.908.286
1.944.634
A-4-10-ii
SEPTIKEMIA SEDANG
2.080.451
2.142.865
2.184.474
2.226.083
A-4-10-iii
SEPTIKEMIA BERAT
3.261.755
3.359.608
3.424.843
3.490.078
A-4-11-i
3.266.319
3.364.308
3.429.634
3.494.961
A-4-11-ii

SEDANG
5.046.085
5.197.467
5.298.389
5.399.311
A-4-11-iii
8.254.292
8.501.921
8.667.007
8.832.093
A-4-12-i
DEMAM RINGAN
1.281.320
1.319.759
1.345.386
1.371.012
A-4-12-ii
DEMAM SEDANG
1.837.776
1.892.909
1.929.665
1.966.420
A-4-12-iii
DEMAM BERAT
2.103.200
2.166.296
2.208.360
2.250.424
10
A-4-13-i
1.601.650
1.649.699
1.681.732
1.713.765
11
A-4-13-ii
1.921.980
1.979.639
2.018.079
2.056.518
12
A-4-13-iii
2.335.939
2.406.017
2.452.736
2.499.455
13
A-4-14-i
1.281.320
1.319.759
1.345.386
1.371.012
14
A-4-14-ii
2.035.004
2.096.054
2.136.754
2.177.454
15
A-4-14-iii
2.317.303
2.386.822
2.433.168
2.479.514
16
A-4-15-i
INFEKSI HIV RINGAN
1.921.980
1.979.639
2.018.079
2.056.518
17
A-4-15-ii
INFEKSI HIV SEDANG
2.882.970
2.969.459
3.027.118
3.084.778
18
A-4-15-iii
INFEKSI HIV BERAT
4.009.532
4.129.817
4.210.008
4.290.199
19
B-1-01-i
21.308.142
21.947.386
22.373.549
22.799.712
20
B-1-01-ii
23.508.577
24.213.835
24.684.006
25.154.178
21
B-1-01-iii
41.238.882
42.476.049
43.300.826
44.125.604
22
B-1-10-i
2.762.528
2.845.404
2.900.655
2.955.905
23
B-1-10-ii
7.040.253
7.251.460
7.392.265
7.533.070
24
B-1-10-iii
12.254.294
12.621.923
12.867.009
13.112.095
25
B-1-11-i
1.888.549
1.945.205
1.982.976
2.020.747
26
B-1-11-ii
4.740.436
4.882.649
4.977.458
5.072.267
27
B-1-11-iii
5.943.331
6.121.630
6.240.497
6.359.364
28
B-1-12-i
4.028.343
4.149.193
4.229.760
4.310.327
29
B-1-12-ii
8.633.725
8.892.736
9.065.411
9.238.085
30
B-1-12-iii
10.507.568
10.822.795
11.032.947
11.243.098

LAIN-LAIN RINGAN
LAIN-LAIN SEDANG
LAIN-LAIN BERAT

(RINGAN)
(SEDANG)
(BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT
- 1011 No
Kode
INA-CBG
31
B-1-13-i
32
B-1-13-ii
33
B-1-13-iii
34
B-1-14-i
35
B-1-14-ii
36
B-1-14-iii
37
B-4-10-i
38
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.639.684
2.718.874
2.771.668
2.824.461
4.299.661
4.428.651
4.514.645
4.600.638
6.338.908
6.529.075
6.655.853
6.782.631
3.584.505
3.692.040
3.763.730
3.835.420
3.986.692
4.106.293
4.186.027
4.265.761
6.236.706
6.423.808
6.548.542
6.673.276
1.002.468
1.032.542
1.052.591
1.072.641
B-4-10-ii
1.601.650
1.649.699
1.681.732
1.713.765
39
B-4-10-iii
2.448.732
2.522.194
2.571.169
2.620.144
40
B-4-11-i
2.421.352
2.493.993
2.542.420
2.590.847
41
B-4-11-ii
3.681.060
3.791.491
3.865.113
3.938.734
42
B-4-11-iii
3.964.629
4.083.568
4.162.861
4.242.153
43
B-4-12-i
2.124.570
2.188.308
2.230.799
2.273.290
44
B-4-12-ii
3.012.118
3.102.482
3.162.724
3.222.966
45
B-4-12-iii
5.854.322
6.029.952
6.147.038
6.264.125
46
B-4-13-i
1.921.980
1.979.639
2.018.079
2.056.518
47
B-4-13-ii
2.999.355
3.089.335
3.149.323
3.209.310
48
B-4-13-iii
4.552.384
4.688.956
4.780.003
4.871.051
49
B-4-14-i
1.921.980
1.979.639
2.018.079
2.056.518
50
B-4-14-ii
2.242.310
2.309.579
2.354.425
2.399.271
51
B-4-14-iii
2.991.467
3.081.211
3.141.040
3.200.869
52
C-4-10-i
1.871.620
1.927.769
1.965.201
2.002.634
53
C-4-10-ii
3.636.362
3.745.453
3.818.180
3.890.907
54
C-4-10-iii
LEUKEMIA AKUT BERAT
6.086.269
6.268.857
6.390.583
6.512.308
55
C-4-11-i
1.921.980
1.979.639
2.018.079
2.056.518
56
C-4-11-ii
2.562.640
2.639.519
2.690.772
2.742.024
57
C-4-11-iii
4.356.787
4.487.491
4.574.627
4.661.763
58
C-4-12-i
RADIOTERAPI RINGAN
1.281.320
1.319.759
1.345.386
1.371.012
59
C-4-12-ii
RADIOTERAPI SEDANG
3.527.860
3.633.696
3.704.253
3.774.811
60
C-4-12-iii
RADIOTERAPI BERAT
7.162.263
7.377.131
7.520.377
7.663.622
61
C-4-13-i
KEMOTERAPI RINGAN
1.281.320
1.319.759
1.345.386
1.371.012
62
C-4-13-ii
KEMOTERAPI SEDANG
2.562.640
2.639.519
2.690.772
2.742.024
63
C-4-13-iii
KEMOTERAPI BERAT
3.353.024
3.453.615
3.520.676
3.587.736

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
LAPAROSKOPIK RINGAN
LAPAROSKOPIK SEDANG
LAPAROSKOPIK BERAT

PANCREAS RINGAN
PANCREAS SEDANG
PANCREAS BERAT
(RINGAN)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT
- 1012 No
Kode
INA-CBG
64
C-4-14-i
65
C-4-14-ii
66
C-4-14-iii
67
D-1-10-i
68
D-1-10-ii
69
D-1-10-iii
70
D-1-11-i
71
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.661.529
1.711.375
1.744.605
1.777.836
2.427.932
2.500.770
2.549.329
2.597.888
3.701.313
3.812.352
3.886.378
3.960.405
13.634.763
14.043.806
14.316.501
14.589.196
20.766.789
21.389.793
21.805.129
22.220.465
28.144.674
28.989.014
29.551.908
30.114.801
2.802.508
2.886.584
2.942.634
2.998.684
D-1-11-ii
7.309.456
7.528.740
7.674.929
7.821.118
72
D-1-11-iii
10.356.298
10.666.987
10.874.113
11.081.239
73
D-1-20-i
3.452.099
3.555.662
3.624.704
3.693.746
74
D-1-20-ii
7.767.223
8.000.240
8.155.584
8.310.929
75
D-1-20-iii
14.040.542
14.461.758
14.742.569
15.023.380
76
D-4-10-i
1.230.786
1.267.710
1.292.326
1.316.941
77
D-4-10-ii
2.485.189
2.559.745
2.609.449
2.659.153
78
D-4-10-iii
3.203.300
3.299.399
3.363.465
3.427.531
79
D-4-11-i
2.802.887
2.886.974
2.943.031
2.999.089
80
D-4-11-ii
5.009.514
5.159.799
5.259.989
5.360.179
81
D-4-11-iii
6.858.324
7.064.074
7.201.240
7.338.407
82
D-4-12-i
1.642.987
1.692.277
1.725.136
1.757.996
83
D-4-12-ii
2.278.985
2.347.354
2.392.934
2.438.513
84
D-4-12-iii
3.499.382
3.604.364
3.674.351
3.744.339
85
D-4-13-i
1.281.320
1.319.759
1.345.386
1.371.012
86
D-4-13-ii
1.921.980
1.979.639
2.018.079
2.056.518
87
D-4-13-iii
2.242.310
2.309.579
2.354.425
2.399.271
88
D-4-14-i
1.543.834
1.590.149
1.621.026
1.651.903
89
D-4-14-ii
3.604.475
3.712.609
3.784.699
3.856.788
90
D-4-14-iii
4.299.640
4.428.629
4.514.622
4.600.615
91
E-1-01-i
3.071.459
3.163.603
3.225.032
3.286.461
92
E-1-01-ii
4.023.319
4.144.019
4.224.485
4.304.952
93
E-1-01-iii
9.118.946
9.392.515
9.574.894
9.757.272
94
E-1-10-i
3.129.652
3.223.542
3.286.135
3.348.728
95
E-1-10-ii
3.798.663
3.912.623
3.988.597
4.064.570
96
E-1-10-iii
8.006.464
8.246.658
8.406.787
8.566.917

RINGAN
SEDANG
BERAT
TULANG RINGAN
TULANG SEDANG
TULANG BERAT


RINGAN
SEDANG
BERAT
- 1013 No
Kode
INA-CBG
97
E-1-20-i
98
E-1-20-ii
99
E-1-20-iii
100
E-4-10-i
101
E-4-10-ii
102
E-4-10-iii
103
E-4-11-i
104
E-4-11-ii
105
E-4-11-iii
106
E-4-12-i
107
E-4-12-ii
108
E-4-12-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.624.202
3.732.928
3.805.412
3.877.896
4.854.033
4.999.654
5.096.735
5.193.816
10.755.166
11.077.821
11.292.924
11.508.028
1.601.650
1.649.699
1.681.732
1.713.765
2.277.883
2.346.220
2.391.777
2.437.335
4.354.129
4.484.753
4.571.835
4.658.918
1.366.542
1.407.539
1.434.869
1.462.200
2.585.263
2.662.821
2.714.526
2.766.232
4.263.218
4.391.115
4.476.379
4.561.644
1.632.827
1.681.812
1.714.468
1.747.125
2.836.528
2.921.624
2.978.355
3.035.085
4.631.833
4.770.788
4.863.425
4.956.062
1.722.313
1.773.982
1.808.429
1.842.875
2.957.223
3.045.940
3.105.085
3.164.229
5.116.743
5.270.246
5.372.580
5.474.915

RINGAN
SEDANG
BERAT

RINGAN
SEDANG
BERAT
109
E-4-13-i
110
E-4-13-ii
111
E-4-13-iii
112
F-4-10-i
SCHIZOFRENIA RINGAN
2.105.853
2.169.029
2.211.146
2.253.263
113
F-4-10-ii
SCHIZOFRENIA SEDANG
2.338.618
2.408.776
2.455.549
2.502.321
114
F-4-10-iii
SCHIZOFRENIA BERAT
3.462.375
3.566.247
3.635.494
3.704.742
115
F-4-11-i
1.941.087
1.999.319
2.038.141
2.076.963
116
F-4-11-ii
2.261.550
2.329.397
2.374.628
2.419.859
117
F-4-11-iii
DEPRESI MAYOR BERAT
2.900.134
2.987.138
3.045.141
3.103.143

IMPULSE RINGAN
IMPULSE SEDANG
IMPULSE BERAT
960.990
989.820
1.009.039
1.028.259
1.372.157
1.413.322
1.440.765
1.468.208
2.976.665
3.065.965
3.125.498
3.185.031
118
F-4-12-i
119
F-4-12-ii
120
F-4-12-iii
121
F-4-13-i
1.568.693
1.615.754
1.647.128
1.678.501
122
F-4-13-ii
2.077.353
2.139.673
2.181.220
2.222.767
123
F-4-13-iii
2.678.481
2.758.835
2.812.405
2.865.975
124
F-4-14-i
DEPRESI RINGAN
1.098.085
1.131.028
1.152.989
1.174.951
125
F-4-14-ii
DEPRESI SEDANG
1.408.517
1.450.772
1.478.943
1.507.113
126
F-4-14-iii
DEPRESI BERAT
1.895.222
1.952.079
1.989.983
2.027.888
127
F-4-15-i
1.305.561
1.344.727
1.370.839
1.396.950
128
F-4-15-ii
1.921.980
1.979.639
2.018.079
2.056.518
129
F-4-15-iii
2.531.365
2.607.306
2.657.933
2.708.561
- 1014 No
Kode
INA-CBG
130
F-4-16-i
131
F-4-16-ii
132
F-4-16-iii
133
F-4-17-i
134
F-4-17-ii
135
F-4-17-iii
136
F-4-18-i
137
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.811.922
2.896.280
2.952.518
3.008.757
3.268.789
3.366.853
3.432.229
3.497.604
4.363.288
4.494.187
4.581.452
4.668.718
649.240
668.717
681.702
694.686
1.902.859
1.959.945
1.998.002
2.036.059
2.030.211
2.091.117
2.131.721
2.172.326
2.437.279
2.510.398
2.559.143
2.607.889
F-4-18-ii
2.681.696
2.762.147
2.815.781
2.869.414
138
F-4-18-iii
4.134.068
4.258.090
4.340.771
4.423.453
139
F-4-19-i
1.869.163
1.925.238
1.962.622
2.000.005
140
F-4-19-ii
2.393.512
2.465.317
2.513.187
2.561.058
141
F-4-19-iii
2.979.954
3.069.353
3.128.952
3.188.551
142
G-1-01-i
5.942.469
6.120.743
6.239.593
6.358.442
143
G-1-01-ii
10.058.345
10.360.095
10.561.262
10.762.429
144
G-1-01-iii
19.471.833
20.055.988
20.445.424
20.834.861
145
G-1-10-i
2.965.592
3.054.560
3.113.871
3.173.183
146
G-1-10-ii
4.186.678
4.312.279
4.396.012
4.479.746
147
G-1-10-iii
4.962.108
5.110.971
5.210.214
5.309.456
148
G-1-11-i
3.420.899
3.523.526
3.591.944
3.660.362
149
G-1-11-ii
7.025.073
7.235.825
7.376.327
7.516.828
150
G-1-11-iii
14.709.865
15.151.161
15.445.358
15.739.555
151
G-1-12-i
2.660.451
2.740.265
2.793.474
2.846.683
152
G-1-12-ii
6.090.838
6.273.563
6.395.380
6.517.197
153
G-1-12-iii
10.742.903
11.065.190
11.280.048
11.494.906
154
G-1-13-i
701.644
722.693
736.726
750.759
155
G-1-13-ii
1.884.539
1.941.075
1.978.765
2.016.456
156
G-1-13-iii
4.252.313
4.379.882
4.464.928
4.549.975
3.352.395
3.452.967
3.520.015
3.587.063
4.529.195
4.665.071
4.755.655
4.846.239
11.089.202
11.421.878
11.643.662
11.865.446

RINGAN
SEDANG
BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

KRANIAL RINGAN
KRANIAL SEDANG
KRANIAL BERAT

RINGAN
SEDANG
BERAT
157
G-1-20-i
158
G-1-20-ii
159
G-1-20-iii
160
G-1-30-i
4.275.678
4.403.948
4.489.462
4.574.975
161
G-1-30-ii
11.159.929
11.494.727
11.717.926
11.941.125
162
G-1-30-iii
14.366.278
14.797.266
15.084.592
15.371.917
- 1015 No
Kode
INA-CBG
163
G-4-10-i
164
G-4-10-ii
165
G-4-10-iii
166
G-4-11-i
167
G-4-11-ii
168
G-4-11-iii
169
G-4-12-i
170
G-4-12-ii
171
G-4-12-iii
172
G-4-13-i
173
G-4-13-ii
174
G-4-13-iii
175
G-4-14-i
176
G-4-14-ii
177
G-4-14-iii
178
G-4-15-i
179
G-4-15-ii
180
G-4-15-iii
181
G-4-16-i
182
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.921.980
1.979.639
2.018.079
2.056.518
2.242.310
2.309.579
2.354.425
2.399.271
3.425.627
3.528.396
3.596.909
3.665.421
3.171.129
3.266.263
3.329.685
3.393.108
3.678.509
3.788.865
3.862.435
3.936.005
5.390.919
5.552.647
5.660.465
5.768.283
2.371.725
2.442.877
2.490.312
2.537.746
2.988.374
3.078.025
3.137.793
3.197.560
4.340.257
4.470.465
4.557.270
4.644.075
1.319.612
1.359.200
1.385.593
1.411.985
2.242.310
2.309.579
2.354.425
2.399.271
2.650.728
2.730.250
2.783.265
2.836.279
2.413.374
2.485.775
2.534.042
2.582.310
3.970.814
4.089.939
4.169.355
4.248.771
4.971.550
5.120.696
5.220.127
5.319.558
2.470.158
2.544.263
2.593.666
2.643.069
2.984.816
3.074.360
3.134.057
3.193.753
3.688.418
3.799.071
3.872.839
3.946.607
1.601.650
1.649.699
1.681.732
1.713.765
G-4-16-ii
2.395.282
2.467.140
2.515.046
2.562.952
183
G-4-16-iii
4.347.008
4.477.419
4.564.359
4.651.299
184
G-4-17-i
2.288.904
2.357.571
2.403.349
2.449.127
185
G-4-17-ii
2.840.631
2.925.850
2.982.662
3.039.475
186
G-4-17-iii
4.760.920
4.903.748
4.998.966
5.094.185
187
G-4-18-i
1.921.980
1.979.639
2.018.079
2.056.518
188
G-4-18-ii
2.755.786
2.838.460
2.893.576
2.948.691
189
G-4-18-iii
2.919.475
3.007.059
3.065.449
3.123.838
190
G-4-19-i
1.601.650
1.649.699
1.681.732
1.713.765
191
G-4-19-ii
3.245.959
3.343.337
3.408.257
3.473.176

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
DEGENERATIF RINGAN
DEGENERATIF SEDANG
DEGENERATIF BERAT
RINGAN
SEDANG
BERAT
TRAUMATIK RINGAN
TRAUMATIK SEDANG
TRAUMATIK BERAT
DENGAN INFARK BERAT
TANPA INFARK RINGAN
TANPA INFARK SEDANG
TANPA INFARK BERAT

PERIFER RINGAN
PERIFER SEDANG
PERIFER BERAT
PERSARAFAN RINGAN
PERSARAFAN SEDANG
PERSARAFAN BERAT
RINGAN
SEDANG
- 1016 No
Kode
INA-CBG
192
G-4-19-iii
193
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

4.841.940
4.987.198
5.084.037
5.180.876
G-4-20-i
1.121.155
1.154.790
1.177.213
1.199.636
194
G-4-20-ii
1.592.041
1.639.802
1.671.643
1.703.484
195
G-4-20-iii
2.714.803
2.796.247
2.850.543
2.904.839
196
G-4-21-i
1.299.162
1.338.137
1.364.120
1.390.103
197
G-4-21-ii
2.690.695
2.771.415
2.825.229
2.879.043
198
G-4-21-iii
3.169.956
3.265.054
3.328.453
3.391.852
199
G-4-22-i
1.281.320
1.319.759
1.345.386
1.371.012
200
G-4-22-ii
1.601.650
1.649.699
1.681.732
1.713.765
201
G-4-22-iii
1.837.511
1.892.636
1.929.387
1.966.137
202
G-4-23-i
1.281.320
1.319.759
1.345.386
1.371.012
203
G-4-23-ii
1.601.650
1.649.699
1.681.732
1.713.765
204
G-4-23-iii
2.289.445
2.358.128
2.403.917
2.449.706
205
G-4-24-i
1.281.320
1.319.759
1.345.386
1.371.012
206
G-4-24-ii
1.601.650
1.649.699
1.681.732
1.713.765
207
G-4-24-iii
TRAUMA KEPALA BERAT
3.365.694
3.466.665
3.533.978
3.601.292
208
G-4-25-i
GEGAR OTAK RINGAN
1.217.504
1.254.029
1.278.379
1.302.729
209
G-4-25-ii
GEGAR OTAK SEDANG
1.532.864
1.578.850
1.609.508
1.640.165
210
G-4-25-iii
GEGAR OTAK BERAT
1.999.964
2.059.963
2.099.962
2.139.962
211
G-4-26-i
1.921.980
1.979.639
2.018.079
2.056.518
212
G-4-26-ii
2.242.310
2.309.579
2.354.425
2.399.271
213
G-4-26-iii
4.280.256
4.408.663
4.494.268
4.579.873
214
H-1-20-i
1.841.758
1.897.011
1.933.846
1.970.682
215
H-1-20-ii
3.358.655
3.459.415
3.526.588
3.593.761
216
H-1-20-iii
4.567.561
4.704.588
4.795.939
4.887.290
1.803.257
1.857.355
1.893.420
1.929.485
2.055.713
2.117.384
2.158.499
2.199.613

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)

RINGAN
SEDANG
217
H-1-30-i
218
H-1-30-ii
219
H-1-30-iii
3.429.883
3.532.779
3.601.377
3.669.974
220
H-4-10-i
1.921.980
1.979.639
2.018.079
2.056.518
221
H-4-10-ii
3.203.300
3.299.399
3.363.465
3.427.531
222
H-4-10-iii
5.222.324
5.378.994
5.483.441
5.587.887
223
H-4-11-i
1.308.657
1.347.917
1.374.090
1.400.263
224
H-4-11-ii
1.462.229
1.506.096
1.535.341
1.564.585
225
H-4-11-iii
2.090.851
2.153.577
2.195.394
2.237.211
- 1017 No
Kode
INA-CBG
226
H-4-12-i
227
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.815.709
1.870.181
1.906.495
1.942.809
H-4-12-ii
2.459.497
2.533.282
2.582.472
2.631.662
228
H-4-12-iii
4.103.503
4.226.608
4.308.678
4.390.748
229
I-1-01-i
27.642.940
28.472.229
29.025.087
29.577.946
230
I-1-01-ii
28.251.229
29.098.766
29.663.791
30.228.815
231
I-1-01-iii
44.594.023
45.931.844
46.823.725
47.715.605
232
I-1-02-i
15.336.144
15.796.228
16.102.951
16.409.674
233
I-1-02-ii
19.783.626
20.377.135
20.772.807
21.168.480
234
I-1-02-iii
24.384.469
25.116.003
25.603.693
26.091.382
235
I-1-03-i
9.444.543
9.727.879
9.916.770
10.105.661
236
I-1-03-ii
12.945.372
13.333.733
13.592.641
13.851.548
237
I-1-03-iii
18.986.546
19.556.142
19.935.873
20.315.604
238
I-1-04-i
11.522.066
11.867.728
12.098.169
12.328.610
239
I-1-04-ii
14.800.298
15.244.307
15.540.313
15.836.319
240
I-1-04-iii
31.551.163
32.497.698
33.128.721
33.759.744
241
I-1-05-i
20.297.838
20.906.773
21.312.730
21.718.686
242
I-1-05-ii
24.357.405
25.088.127
25.575.276
26.062.424
243
I-1-05-iii
33.515.636
34.521.105
35.191.418
35.861.731
244
I-1-06-i
9.567.951
9.854.989
10.046.348
10.237.707
245
I-1-06-ii
14.440.308
14.873.518
15.162.324
15.451.130
246
I-1-06-iii
18.589.840
19.147.535
19.519.332
19.891.128
12.582.579
12.960.057
13.211.708
13.463.360
15.523.168
15.988.863
16.299.326
16.609.790
16.935.675
17.443.745
17.782.459
18.121.172
2.393.513
2.465.319
2.513.189
2.561.059
2.661.348
2.741.188
2.794.415
2.847.642
3.541.442
3.647.686
3.718.515
3.789.343
7.335.711
7.555.782
7.702.496
7.849.211
10.178.641
10.484.001
10.687.573
10.891.146
247
I-1-07-i
248
I-1-07-ii
249
I-1-07-iii
250
I-1-11-i
251
I-1-11-ii
252
I-1-11-iii
253
I-1-12-i
254
I-1-12-ii

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
KATETERISASI RINGAN
KATETERISASI SEDANG
KATETERISASI BERAT
RINGAN
SEDANG
BERAT

KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
- 1018 No
Kode
INA-CBG
255
I-1-12-iii
256
I-1-13-i
257
I-1-13-ii
258
I-1-13-iii
259
I-1-14-i
260
I-1-14-ii
261
I-1-14-iii
262
I-1-15-i
263
264
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
14.196.802
14.622.706
14.906.642
15.190.578
4.315.124
4.444.578
4.530.880
4.617.183
5.020.382
5.170.994
5.271.401
5.371.809
9.151.821
9.426.376
9.609.412
9.792.449
15.787.207
16.260.823
16.576.568
16.892.312
19.621.243
20.209.880
20.602.305
20.994.730
25.710.594
26.481.912
26.996.124
27.510.336
3.093.535
3.186.342
3.248.212
3.310.083
I-1-15-ii
9.061.761
9.333.613
9.514.849
9.696.084
I-1-15-iii
46.905.026
48.312.176
49.250.277
50.188.377
6.765.946
6.968.924
7.104.243
7.239.562
17.591.459
18.119.203
18.471.032
18.822.862
20.291.317
20.900.056
21.305.883
21.711.709
2.169.893
2.234.990
2.278.388
2.321.786
4.494.636
4.629.475
4.719.367
4.809.260
26.057.163
26.838.878
27.360.021
27.881.165
2.589.074
2.666.747
2.718.528
2.770.310
4.660.334
4.800.144
4.893.350
4.986.557
6.213.779
6.400.192
6.524.468
6.648.743
7.676.001
7.906.281
8.059.801
8.213.321
15.967.632
16.446.661
16.766.014
17.085.367
24.744.031
25.486.352
25.981.232
26.476.113
10.322.491
10.632.165
10.838.615
11.045.065
14.335.722
14.765.794
15.052.508
15.339.223
17.963.317
18.502.217
18.861.483
19.220.749

KOMPLEKS BERAT
KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

DARAH VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
265
I-1-16-i
266
I-1-16-ii
267
I-1-16-iii
268
I-1-17-i
269
I-1-17-ii
270
I-1-17-iii
271
I-1-20-i
272
I-1-20-ii
273
I-1-20-iii
274
I-1-30-i
275
I-1-30-ii
276
I-1-30-iii
277
I-1-40-i
278
I-1-40-ii
279
I-1-40-iii
280
I-4-10-i
3.002.080
3.092.143
3.152.184
3.212.226
281
I-4-10-ii
4.740.339
4.882.549
4.977.355
5.072.162
282
I-4-10-iii
6.838.352
7.043.502
7.180.269
7.317.036
283
I-4-11-i
3.559.682
3.666.473
3.737.666
3.808.860
- 1019 No
Kode
INA-CBG
284
I-4-11-ii
285
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.405.120
4.537.274
4.625.376
4.713.479
I-4-11-iii
7.796.018
8.029.898
8.185.819
8.341.739
286
I-4-12-i
3.117.912
3.211.449
3.273.807
3.336.165
287
I-4-12-ii
4.449.251
4.582.728
4.671.713
4.760.698
288
I-4-12-iii
5.397.567
5.559.494
5.667.446
5.775.397
289
I-4-13-i
2.800.742
2.884.764
2.940.779
2.996.794
290
I-4-13-ii
4.068.906
4.190.973
4.272.351
4.353.729
291
I-4-13-iii
8.328.579
8.578.436
8.745.008
8.911.579
292
I-4-14-i
1.741.803
1.794.057
1.828.893
1.863.729
293
I-4-14-ii
2.038.167
2.099.312
2.140.075
2.180.838
294
I-4-14-iii
3.158.480
3.253.235
3.316.404
3.379.574
295
I-4-15-i
2.562.640
2.639.519
2.690.772
2.742.024
296
I-4-15-ii
3.668.546
3.778.602
3.851.973
3.925.344
297
I-4-15-iii
4.181.259
4.306.697
4.390.322
4.473.947
298
I-4-16-i
1.921.980
1.979.639
2.018.079
2.056.518
299
I-4-16-ii
3.114.867
3.208.313
3.270.611
3.332.908
300
I-4-16-iii
3.924.179
4.041.905
4.120.388
4.198.872
301
I-4-17-i
HIPERTENSI RINGAN
1.720.132
1.771.736
1.806.139
1.840.541
302
I-4-17-ii
HIPERTENSI SEDANG
2.435.878
2.508.955
2.557.672
2.606.390
303
I-4-17-iii
HIPERTENSI BERAT
2.963.362
3.052.263
3.111.530
3.170.798
304
I-4-18-i
2.533.260
2.609.258
2.659.923
2.710.589
305
I-4-18-ii
3.880.785
3.997.209
4.074.825
4.152.440
306
I-4-18-iii
5.231.921
5.388.878
5.493.517
5.598.155
307
I-4-19-i
1.982.608
2.042.087
2.081.739
2.121.391
308
I-4-19-ii
3.247.450
3.344.874
3.409.823
3.474.772
309
I-4-19-iii
3.870.931
3.987.059
4.064.478
4.141.896
310
I-4-20-i
2.406.176
2.478.361
2.526.485
2.574.608
311
I-4-20-ii
2.772.095
2.855.257
2.910.699
2.966.141
312
I-4-20-iii
3.679.031
3.789.402
3.862.982
3.936.563
313
I-4-21-i
3.199.825
3.295.819
3.359.816
3.423.812
314
I-4-21-ii
3.991.574
4.111.321
4.191.152
4.270.984
315
I-4-21-iii
5.445.353
5.608.714
5.717.621
5.826.528
316
I-4-22-i
2.082.145
2.144.609
2.186.252
2.227.895

VENA RINGAN
DARAH VENA SEDANG
DARAH VENA BERAT


RINGAN
SEDANG
KONGENITAL BERAT
RINGAN
SEDANG
BERAT
- 1020 No
Kode
INA-CBG
317
I-4-22-ii
318
I-4-22-iii
319
I-4-23-i
320
I-4-23-ii
321
I-4-23-iii
322
I-4-24-i
323
I-4-24-ii
324
I-4-24-iii
325
J-1-01-i
326
J-1-01-ii
327
J-1-01-iii
328
J-1-02-i
329
J-1-02-ii
330
J-1-02-iii
331
J-1-10-i
332
J-1-10-ii
333
J-1-10-iii
334
J-1-20-i
335
J-1-20-ii
336
J-1-20-iii
337
J-1-30-i
338
J-1-30-ii
339
J-1-30-iii
340
J-4-10-i
341
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.399.254
2.471.232
2.519.217
2.567.202
3.500.446
3.605.460
3.675.469
3.745.478
1.577.342
1.624.662
1.656.209
1.687.756
1.936.613
1.994.711
2.033.443
2.072.175
3.783.964
3.897.483
3.973.163
4.048.842
1.881.314
1.937.753
1.975.379
2.013.006
4.697.120
4.838.033
4.931.976
5.025.918
5.938.659
6.116.819
6.235.592
6.354.365
15.450.441
15.913.954
16.222.963
16.531.972
16.828.984
17.333.853
17.670.433
18.007.013
24.954.252
25.702.880
26.201.965
26.701.050
6.988.924
7.198.592
7.338.370
7.478.149
7.487.000
7.711.610
7.861.350
8.011.090
11.063.652
11.395.562
11.616.835
11.838.108
2.727.179
2.808.995
2.863.538
2.918.082
6.587.129
6.784.743
6.916.485
7.048.228
11.663.321
12.013.221
12.246.487
12.479.754
2.357.156
2.427.870
2.475.013
2.522.156
3.428.297
3.531.145
3.599.711
3.668.277
5.155.099
5.309.752
5.412.854
5.515.956
1.589.560
1.637.247
1.669.038
1.700.829
8.630.248
8.889.156
9.061.761
9.234.365
26.028.449
26.809.303
27.329.872
27.850.441
2.033.830
2.094.845
2.135.522
2.176.198
J-4-10-ii
2.908.133
2.995.377
3.053.539
3.111.702
342
J-4-10-iii
4.399.571
4.531.558
4.619.549
4.707.541
343
J-4-11-i
1.157.377
1.192.098
1.215.246
1.238.393
344
J-4-11-ii
1.611.042
1.659.373
1.691.594
1.723.815
345
J-4-11-iii
2.308.665
2.377.924
2.424.098
2.470.271
346
J-4-12-i
EMBOLI PARU RINGAN
1.962.175
2.021.040
2.060.284
2.099.527
347
J-4-12-ii
EMBOLI PARU SEDANG
2.540.949
2.617.178
2.667.997
2.718.816

RINGAN
SEDANG
BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
KOMPLEKS RINGAN
KOMPLEKS SEDANG
KOMPLEKS BERAT
- 1021 No
Kode
INA-CBG
348
J-4-12-iii
349
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
EMBOLI PARU BERAT
3.393.181
3.494.976
3.562.840
3.630.704
J-4-13-i
2.726.364
2.808.155
2.862.682
2.917.209
350
J-4-13-ii
4.007.755
4.127.988
4.208.143
4.288.298
351
J-4-13-iii
6.516.010
6.711.490
6.841.810
6.972.131
352
J-4-14-i
TUMOR PARU RINGAN
1.921.980
1.979.639
2.018.079
2.056.518
353
J-4-14-ii
TUMOR PARU SEDANG
3.112.289
3.205.657
3.267.903
3.330.149
354
J-4-14-iii
TUMOR PARU BERAT
3.700.353
3.811.363
3.885.371
3.959.378
355
J-4-15-i
1.921.980
1.979.639
2.018.079
2.056.518
356
J-4-15-ii
2.290.276
2.358.984
2.404.790
2.450.595
357
J-4-15-iii
3.110.027
3.203.328
3.265.528
3.327.729
358
J-4-16-i
1.601.650
1.649.699
1.681.732
1.713.765
359
J-4-16-ii
2.242.310
2.309.579
2.354.425
2.399.271
360
J-4-16-iii
4.044.891
4.166.238
4.247.135
4.328.033
361
J-4-17-i
1.601.650
1.649.699
1.681.732
1.713.765
362
J-4-17-ii
1.921.980
1.979.639
2.018.079
2.056.518
363
J-4-17-iii
3.533.449
3.639.453
3.710.122
3.780.791
364
J-4-18-i
1.281.320
1.319.759
1.345.386
1.371.012
365
J-4-18-ii
1.761.815
1.814.669
1.849.906
1.885.142
366
J-4-18-iii
1.855.083
1.910.736
1.947.837
1.984.939
367
J-4-19-i
2.242.310
2.309.579
2.354.425
2.399.271
368
J-4-19-ii
2.562.640
2.639.519
2.690.772
2.742.024
369
J-4-19-iii
4.014.675
4.135.116
4.215.409
4.295.703
370
J-4-20-i
2.242.310
2.309.579
2.354.425
2.399.271
371
J-4-20-ii
2.562.640
2.639.519
2.690.772
2.742.024
372
J-4-20-iii
6.180.574
6.365.991
6.489.602
6.613.214
373
J-4-21-i
1.281.320
1.319.759
1.345.386
1.371.012
374
J-4-21-ii
3.161.250
3.256.087
3.319.312
3.382.537
375
J-4-21-iii
4.508.976
4.644.246
4.734.425
4.824.605
376
K-1-10-i
3.452.099
3.555.662
3.624.704
3.693.746
377
K-1-10-ii
4.817.631
4.962.160
5.058.513
5.154.865
378
K-1-10-iii
5.642.276
5.811.544
5.924.390
6.037.235
379
K-1-11-i
2.968.274
3.057.323
3.116.688
3.176.054
380
K-1-11-ii
3.896.986
4.013.896
4.091.835
4.169.775

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT

USUS BESAR (RINGAN)
USUS BESAR (SEDANG)
USUS BESAR (BERAT)
- 1022 No
Kode
INA-CBG
381
K-1-11-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
9.889.784
10.186.477
10.384.273
10.582.069
1.596.704
1.644.606
1.676.540
1.708.474
2.081.000
2.143.430
2.185.050
2.226.670
4.139.546
4.263.733
4.346.523
4.429.314
382
K-1-12-i
383
K-1-12-ii
384
K-1-12-iii
385
K-1-13-i
1.813.637
1.868.047
1.904.319
1.940.592
386
K-1-13-ii
3.167.904
3.262.941
3.326.299
3.389.657
387
K-1-13-iii
3.387.959
3.489.597
3.557.357
3.625.116
2.930.945
3.018.874
3.077.493
3.136.112
3.442.727
3.546.009
3.614.864
3.683.718
8.476.993
8.731.303
8.900.843
9.070.383

RINGAN
SEDANG
BERAT
388
K-1-14-i
389
K-1-14-ii
390
K-1-14-iii
391
K-1-20-i
5.686.894
5.857.501
5.971.238
6.084.976
392
K-1-20-ii
7.937.404
8.175.526
8.334.274
8.493.022
393
K-1-20-iii
16.954.670
17.463.310
17.802.403
18.141.497
394
K-1-30-i
3.743.397
3.855.698
3.930.566
4.005.434
395
K-1-30-ii
6.904.198
7.111.324
7.249.408
7.387.492
396
K-1-30-iii
10.752.403
11.074.975
11.290.024
11.505.072
397
K-1-40-i
3.760.694
3.873.515
3.948.728
4.023.942
398
K-1-40-ii
4.138.270
4.262.418
4.345.183
4.427.949
399
K-1-40-iii
6.862.922
7.068.810
7.206.068
7.343.327
400
K-1-50-i
2.868.502
2.954.557
3.011.927
3.069.297
401
K-1-50-ii
3.714.845
3.826.291
3.900.588
3.974.884
402
K-1-50-iii
PROSEDUR ANAL BERAT
5.274.092
5.432.315
5.537.797
5.643.279
403
K-4-10-i
2.172.684
2.237.864
2.281.318
2.324.772
404
K-4-10-ii
2.599.744
2.677.736
2.729.731
2.781.726
405
K-4-10-iii
10.765.506
11.088.471
11.303.781
11.519.091
406
K-4-11-i
1.281.320
1.319.759
1.345.386
1.371.012
407
K-4-11-ii
1.921.980
1.979.639
2.018.079
2.056.518
408
K-4-11-iii
3.492.930
3.597.718
3.667.576
3.737.435
409
K-4-12-i
1.281.320
1.319.759
1.345.386
1.371.012
410
K-4-12-ii
1.914.272
1.971.700
2.009.986
2.048.271
411
K-4-12-iii
4.594.116
4.731.940
4.823.822
4.915.704
412
K-4-13-i

(RINGAN)
1.921.980
1.979.639
2.018.079
2.056.518

(RINGAN)
(SEDANG)
(BERAT)
- 1023 No
Kode
INA-CBG
413
K-4-13-ii
414
K-4-13-iii
415
K-4-14-i
416
K-4-14-ii
417
K-4-14-iii
418
K-4-15-i
419
K-4-15-ii
420
K-4-15-iii
421
K-4-16-i
422
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.489.437
2.564.120
2.613.909
2.663.698
4.071.630
4.193.778
4.275.211
4.356.644
1.601.650
1.649.699
1.681.732
1.713.765
2.167.666
2.232.696
2.276.049
2.319.402
3.278.801
3.377.165
3.442.741
3.508.317
1.601.650
1.649.699
1.681.732
1.713.765
3.011.538
3.101.885
3.162.115
3.222.346
4.284.877
4.413.423
4.499.121
4.584.819
1.601.650
1.649.699
1.681.732
1.713.765
K-4-16-ii
1.921.980
1.979.639
2.018.079
2.056.518
423
K-4-16-iii
2.346.026
2.416.407
2.463.327
2.510.248
424
K-4-17-i
1.281.320
1.319.759
1.345.386
1.371.012
425
K-4-17-ii
1.869.470
1.925.554
1.962.943
2.000.332
426
K-4-17-iii
2.488.073
2.562.715
2.612.477
2.662.238
427
K-4-18-i
1.281.320
1.319.759
1.345.386
1.371.012
428
K-4-18-ii
1.989.140
2.048.814
2.088.597
2.128.380
429
K-4-18-iii
2.353.143
2.423.737
2.470.800
2.517.862
430
L-1-20-i
13.112.068
13.505.430
13.767.671
14.029.913
431
L-1-20-ii
13.640.165
14.049.370
14.322.173
14.594.977
432
L-1-20-iii
20.898.308
21.525.257
21.943.223
22.361.189
433
L-1-30-i
5.947.248
6.125.665
6.244.610
6.363.555
434
L-1-30-ii
8.614.608
8.873.046
9.045.338
9.217.630
435
L-1-30-iii
9.085.723
9.358.295
9.540.010
9.721.724
436
L-1-40-i
2.401.326
2.473.365
2.521.392
2.569.418
437
L-1-40-ii
5.404.663
5.566.803
5.674.897
5.782.990
438
L-1-40-iii
9.159.476
9.434.261
9.617.450
9.800.640
439
L-1-50-i
4.315.124
4.444.578
4.530.880
4.617.183
440
L-1-50-ii
7.767.223
8.000.240
8.155.584
8.310.929
441
L-1-50-iii
9.391.672
9.673.422
9.861.256
10.049.089
442
L-4-10-i
1.921.980
1.979.639
2.018.079
2.056.518
443
L-4-10-ii
2.242.310
2.309.579
2.354.425
2.399.271

(SEDANG)
RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
BAKAR RINGAN
BAKAR SEDANG
BAKAR BERAT
- 1024 No
Kode
INA-CBG
444
L-4-10-iii
445
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.536.001
4.672.081
4.762.801
4.853.521
L-4-11-i
1.817.843
1.872.378
1.908.735
1.945.092
446
L-4-11-ii
2.490.413
2.565.125
2.614.933
2.664.742
447
L-4-11-iii
6.753.688
6.956.299
7.091.373
7.226.446
448
L-4-12-i
1.921.980
1.979.639
2.018.079
2.056.518
449
L-4-12-ii
2.819.990
2.904.590
2.960.990
3.017.390
450
L-4-12-iii
4.728.790
4.870.654
4.965.229
5.059.805
451
L-4-13-i
1.206.369
1.242.560
1.266.687
1.290.814
452
L-4-13-ii
1.391.014
1.432.745
1.460.565
1.488.385
453
L-4-13-iii
2.086.630
2.149.229
2.190.961
2.232.694
454
L-4-14-i
1.281.320
1.319.759
1.345.386
1.371.012
455
L-4-14-ii
1.921.980
1.979.639
2.018.079
2.056.518
456
L-4-14-iii
3.005.050
3.095.201
3.155.302
3.215.403
457
M-1-01-i
6.246.933
6.434.341
6.559.280
6.684.219
458
M-1-01-ii
6.972.588
7.181.766
7.321.218
7.460.669
459
M-1-01-iii
9.794.597
10.088.435
10.284.327
10.480.219
460
M-1-02-i
4.424.422
4.557.155
4.645.643
4.734.132
461
M-1-02-ii
7.264.060
7.481.982
7.627.263
7.772.544
462
M-1-02-iii
13.154.880
13.549.526
13.812.624
14.075.721
463
M-1-03-i
11.219.323
11.555.902
11.780.289
12.004.675
464
M-1-03-ii
13.129.888
13.523.785
13.786.383
14.048.981
465
M-1-03-iii
13.376.885
13.778.191
14.045.729
14.313.266
466
M-1-04-i
2.918.659
3.006.218
3.064.592
3.122.965
467
M-1-04-ii
3.741.690
3.853.941
3.928.775
4.003.608
468
M-1-04-iii
4.682.020
4.822.480
4.916.121
5.009.761
469
M-1-05-i
4.546.710
4.683.111
4.774.045
4.864.979
470
M-1-05-ii
5.254.778
5.412.421
5.517.517
5.622.613
471
M-1-05-iii
8.950.318
9.218.828
9.397.834
9.576.840
472
M-1-07-i
5.018.931
5.169.499
5.269.878
5.370.256
473
M-1-07-ii
6.723.799
6.925.513
7.059.989
7.194.465
474
M-1-07-iii
13.697.017
14.107.927
14.381.867
14.655.808
475
M-1-10-i
3.136.735
3.230.838
3.293.572
3.356.307


TULANG WAJAH RINGAN
- 1025 No
Kode
INA-CBG
476
M-1-10-ii
477
M-1-10-iii
478
M-1-20-i
479
M-1-20-ii
480
M-1-20-iii
481
M-1-30-i
482
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
11.651.551
12.001.097
12.234.128
12.467.159
14.252.067
14.679.629
14.964.671
15.249.712
3.103.042
3.196.133
3.258.194
3.320.255
4.429.314
4.562.193
4.650.779
4.739.366
8.609.620
8.867.909
9.040.101
9.212.294
1.856.083
1.911.765
1.948.887
1.986.009
M-1-30-ii
3.835.139
3.950.194
4.026.896
4.103.599
483
M-1-30-iii
PROSEDUR KAKI BERAT
5.721.219
5.892.856
6.007.280
6.121.705
484
M-1-40-i
1.875.428
1.931.690
1.969.199
2.006.708
485
M-1-40-ii
3.452.099
3.555.662
3.624.704
3.693.746
486
M-1-40-iii
6.041.174
6.222.409
6.343.232
6.464.056
487
M-1-50-i
2.483.767
2.558.280
2.607.956
2.657.631
488
M-1-50-ii
4.999.882
5.149.879
5.249.876
5.349.874
489
M-1-50-iii
6.904.198
7.111.324
7.249.408
7.387.492
490
M-1-60-i
1.874.461
1.930.694
1.968.184
2.005.673
491
M-1-60-ii
3.752.682
3.865.263
3.940.317
4.015.370
492
M-1-60-iii
6.530.995
6.726.925
6.857.545
6.988.165
493
M-1-70-i
2.511.024
2.586.354
2.636.575
2.686.795
494
M-1-70-ii
5.123.732
5.277.444
5.379.918
5.482.393
495
M-1-70-iii
8.260.074
8.507.877
8.673.078
8.838.280
496
M-1-80-i
2.023.205
2.083.902
2.124.366
2.164.830
497
M-1-80-ii
3.058.673
3.150.433
3.211.607
3.272.780
498
M-1-80-iii
7.041.857
7.253.113
7.393.950
7.534.787
499
M-4-10-i
1.281.320
1.319.759
1.345.386
1.371.012
500
M-4-10-ii
1.954.972
2.013.622
2.052.721
2.091.820
501
M-4-10-iii
FRAKTUR FEMUR BERAT
4.151.280
4.275.819
4.358.844
4.441.870
502
M-4-11-i
1.695.762
1.746.634
1.780.550
1.814.465
503
M-4-11-ii
3.890.330
4.007.040
4.084.846
4.162.653
504
M-4-11-iii
6.905.244
7.112.402
7.250.506
7.388.611
505
M-4-12-i
1.281.320
1.319.759
1.345.386
1.371.012
506
M-4-12-ii
2.331.360
2.401.301
2.447.928
2.494.555

TULANG WAJAH SEDANG
TULANG WAJAH BERAT

RINGAN
SEDANG
BERAT

SELAIN KAKI (BERAT)

PANGGUL RINGAN
PANGGUL SEDANG
PANGGUL BERAT
PELVIS RINGAN
PELVIS SEDANG
- 1026 No
Kode
INA-CBG
507
M-4-12-iii
508
M-4-13-i
509
M-4-13-ii
510
M-4-13-iii
511
M-4-14-i
512
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.669.104
4.809.177
4.902.559
4.995.941
2.365.430
2.436.392
2.483.701
2.531.010
3.203.300
3.299.399
3.363.465
3.427.531
7.036.560
7.247.657
7.388.388
7.529.120
2.562.640
2.639.519
2.690.772
2.742.024
M-4-14-ii
3.326.993
3.426.803
3.493.343
3.559.883
513
M-4-14-iii
OSTEOMIELITIS BERAT
4.983.478
5.132.982
5.232.651
5.332.321
514
M-4-15-i
1.598.813
1.646.777
1.678.754
1.710.730
515
M-4-15-ii
2.131.885
2.195.842
2.238.480
2.281.117
516
M-4-15-iii
5.445.609
5.608.978
5.717.890
5.826.802
517
M-4-16-i
1.601.650
1.649.699
1.681.732
1.713.765
518
M-4-16-ii
2.562.640
2.639.519
2.690.772
2.742.024
519
M-4-16-iii
4.765.045
4.907.997
5.003.298
5.098.598
520
M-4-17-i
1.601.650
1.649.699
1.681.732
1.713.765
521
M-4-17-ii
2.242.310
2.309.579
2.354.425
2.399.271
522
M-4-17-iii
3.131.505
3.225.450
3.288.080
3.350.710
523
M-4-18-i
1.877.382
1.933.704
1.971.251
2.008.799
524
M-4-18-ii
2.562.640
2.639.519
2.690.772
2.742.024
525
M-4-18-iii
3.183.931
3.279.449
3.343.127
3.406.806
526
M-4-19-i
1.395.859
1.437.735
1.465.652
1.493.569
527
M-4-19-ii
2.351.074
2.421.606
2.468.628
2.515.649
528
M-4-19-iii
4.591.821
4.729.576
4.821.412
4.913.249
529
M-4-20-i
1.281.320
1.319.759
1.345.386
1.371.012
530
M-4-20-ii
1.921.980
1.979.639
2.018.079
2.056.518
531
M-4-20-iii
2.130.007
2.193.907
2.236.507
2.279.107
532
M-4-21-i
1.281.320
1.319.759
1.345.386
1.371.012
533
M-4-21-ii
1.672.445
1.722.618
1.756.067
1.789.516
534
M-4-21-iii
4.076.714
4.199.016
4.280.550
4.362.084
535
N-1-01-i
3.466.905
3.570.912
3.640.250
3.709.588
536
N-1-01-ii
4.688.911
4.829.578
4.923.356
5.017.134
537
N-1-01-iii
9.941.885
10.240.142
10.438.980
10.637.817

PELVIS BERAT

BELAKANG RINGAN
BELAKANG SEDANG
BELAKANG BERAT
RINGAN
SEDANG
BERAT
ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
- 1027 No
Kode
INA-CBG
538
N-1-11-i
539
N-1-11-ii
540
N-1-11-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
4.782.863
4.926.349
5.022.006
5.117.663
6.468.714
6.662.776
6.792.150
6.921.524
13.715.598
14.127.066
14.401.378
14.675.690
2.589.074
2.666.747
2.718.528
2.770.310
6.023.298
6.203.997
6.324.463
6.444.929
10.977.837
11.307.172
11.526.728
11.746.285
541
N-1-12-i
542
N-1-12-ii
543
N-1-12-iii
544
N-1-20-i
3.505.402
3.610.564
3.680.672
3.750.780
545
N-1-20-ii
6.949.967
7.158.466
7.297.465
7.436.464
546
N-1-20-iii
7.950.132
8.188.636
8.347.638
8.506.641
547
N-1-30-i
4.170.295
4.295.404
4.378.809
4.462.215
548
N-1-30-ii
6.337.283
6.527.401
6.654.147
6.780.893
549
N-1-30-iii
7.295.258
7.514.115
7.660.021
7.805.926
550
N-1-40-i
3.757.844
3.870.579
3.945.736
4.020.893
551
N-1-40-ii
5.093.891
5.246.708
5.348.586
5.450.464
552
N-1-40-iii
5.924.343
6.102.073
6.220.560
6.339.047
553
N-4-10-i
1.601.650
1.649.699
1.681.732
1.713.765
554
N-4-10-ii
2.144.654
2.208.993
2.251.887
2.294.780
555
N-4-10-iii
4.694.261
4.835.089
4.928.974
5.022.859
556
N-4-11-i
1.226.548
1.263.345
1.287.876
1.312.407
557
N-4-11-ii
2.072.837
2.135.022
2.176.479
2.217.936
558
N-4-11-iii
2.402.475
2.474.549
2.522.598
2.570.648
559
N-4-12-i
1.281.320
1.319.759
1.345.386
1.371.012
560
N-4-12-ii
1.921.980
1.979.639
2.018.079
2.056.518
561
N-4-12-iii
3.191.118
3.286.852
3.350.674
3.414.496
562
N-4-13-i
BATU URIN RINGAN
1.690.455
1.741.168
1.774.977
1.808.787
563
N-4-13-ii
BATU URIN SEDANG
2.038.053
2.099.194
2.139.955
2.180.716
564
N-4-13-iii
BATU URIN BERAT
5.019.165
5.169.740
5.270.123
5.370.506
1.109.860
1.143.156
1.165.353
1.187.551
1.709.045
1.760.317
1.794.498
1.828.679
2.771.527
2.854.673
2.910.103
2.965.534
565
N-4-14-i
566
N-4-14-ii
567
N-4-14-iii

URIN BAWAH RINGAN
URIN BAWAH SEDANG
URIN BAWAH BERAT
RINGAN
SEDANG
BERAT
GINJAL RINGAN
GINJAL SEDANG
GINJAL BERAT

(RINGAN)
(SEDANG)
(BERAT)
- 1028 No
Kode
INA-CBG
568
N-4-15-i
569
N-4-15-ii
570
N-4-15-iii
571
N-4-16-i
572
N-4-16-ii
573
N-4-16-iii
574
O-6-10-i
575
O-6-10-ii
576
O-6-10-iii
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
584
585
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.646.565
1.695.961
1.728.893
1.761.824
2.259.599
2.327.387
2.372.579
2.417.771
2.578.610
2.655.968
2.707.541
2.759.113
2.137.013
2.201.124
2.243.864
2.286.604
2.562.640
2.639.519
2.690.772
2.742.024
5.388.850
5.550.515
5.658.292
5.766.069
3.155.406
3.250.068
3.313.176
3.376.284
3.502.981
3.608.071
3.678.130
3.748.190
3.926.884
4.044.690
4.123.228
4.201.766
1.649.128
1.698.602
1.731.584
1.764.567
2.115.680
2.179.151
2.221.464
2.263.778
3.585.422
3.692.984
3.764.693
3.836.401
1.436.068
1.479.150
1.507.872
1.536.593
1.724.714
1.776.456
1.810.950
1.845.444
2.166.856
2.231.862
2.275.199
2.318.536
1.439.199
1.482.375
1.511.159
1.539.943
O-6-13-ii
2.121.097
2.184.730
2.227.152
2.269.574
O-6-13-iii
2.506.809
2.582.014
2.632.150
2.682.286
32.194.235
33.160.062
33.803.947
34.447.832
39.835.330
41.030.390
41.827.097
42.623.803
46.755.511
48.158.176
49.093.286
50.028.397
39.005.829
40.176.004
40.956.120
41.736.237
44.743.701
46.086.012
46.980.886
47.875.760
51.122.877
52.656.563
53.679.021
54.701.479
2.157.562
2.222.289
2.265.440
2.308.591
3.020.587
3.111.204
3.171.616
3.232.028
4.758.109
4.900.853
4.996.015
5.091.177
19.268.544
19.846.601
20.231.972
20.617.342
25.006.416
25.756.609
26.256.737
26.756.865
586
P-8-01-i
587
P-8-01-ii
588
P-8-01-iii
589
P-8-02-i
590
P-8-02-ii
591
P-8-02-iii
592
P-8-03-i
593
P-8-03-ii
594
P-8-03-iii
595
P-8-04-i
596
P-8-04-ii

SALURAN URIN RINGAN
SALURAN URIN SEDANG
SALURAN URIN BERAT
RINGAN
SEDANG
BERAT
&KURET RINGAN
KURET SEDANG
KURET BERAT

- 1029 No
Kode
INA-CBG
597
P-8-04-iii
598
P-8-05-i
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii
603
P-8-06-iii
604
P-8-07-i
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
614
P-8-11-ii
615
P-8-11-iii
616
P-8-12-i
617
P-8-12-ii
618
P-8-12-iii
619
P-8-13-i
620
P-8-13-ii
621
P-8-13-iii
622
P-8-14-i
623
P-8-14-ii
624
P-8-14-iii
Deskripsi (INA-CBG)
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
RINGAN
SEDANG
BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
35.852.906
36.928.494
37.645.552
38.362.610
10.477.610
10.791.938
11.001.490
11.211.042
14.850.599
15.296.117
15.593.129
15.890.141
21.880.364
22.536.775
22.974.382
23.411.990
1.726.050
1.777.831
1.812.352
1.846.873
4.343.193
4.473.489
4.560.353
4.647.217
8.078.835
8.321.200
8.482.776
8.644.353
3.020.587
3.111.204
3.171.616
3.232.028
8.468.998
8.723.068
8.892.448
9.061.828
11.219.323
11.555.902
11.780.289
12.004.675
2.188.964
2.254.633
2.298.413
2.342.192
3.107.543
3.200.769
3.262.920
3.325.071
4.386.896
4.518.503
4.606.241
4.693.979
1.358.031
1.398.772
1.425.932
1.453.093
1.967.305
2.026.325
2.065.671
2.105.017
3.862.400
3.978.272
4.055.520
4.132.768
3.824.792
3.939.536
4.016.032
4.092.528
8.142.878
8.387.164
8.550.022
8.712.879
8.313.472
8.562.877
8.729.146
8.895.416
1.804.437
1.858.570
1.894.658
1.930.747
2.805.586
2.889.753
2.945.865
3.001.977
3.309.998
3.409.298
3.475.498
3.541.697
932.630
960.609
979.262
997.914
1.725.825
1.777.599
1.812.116
1.846.632
2.581.155
2.658.590
2.710.213
2.761.836
1.704.012
1.755.133
1.789.213
1.823.293
3.479.111
3.583.484
3.653.066
3.722.648
3.816.571
3.931.069
4.007.400
4.083.731
- 1030 No
Kode
INA-CBG
625
P-8-15-i
626
P-8-15-ii
627
P-8-15-iii
628
P-8-16-i
629
P-8-16-ii
630
P-8-16-iii
631
P-8-17-i
632
P-8-17-ii
633
P-8-17-iii
634
S-4-10-i
635
S-4-10-ii
636
S-4-10-iii
637
S-4-11-i
638
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.281.470
1.319.914
1.345.544
1.371.173
2.561.322
2.638.162
2.689.388
2.740.615
3.008.669
3.098.930
3.159.103
3.219.276
1.160.034
1.194.835
1.218.035
1.241.236
1.645.557
1.694.924
1.727.835
1.760.746
2.136.014
2.200.094
2.242.815
2.285.535
765.620
788.588
803.901
819.213
2.543.129
2.619.423
2.670.286
2.721.148
5.133.144
5.287.139
5.389.802
5.492.464
1.281.320
1.319.759
1.345.386
1.371.012
1.601.650
1.649.699
1.681.732
1.713.765
2.081.870
2.144.326
2.185.963
2.227.601
800.825
824.850
840.866
856.883
S-4-11-ii
1.218.871
1.255.437
1.279.814
1.304.192
639
S-4-11-iii
1.971.919
2.031.077
2.070.515
2.109.954
640
S-4-12-i
960.990
989.820
1.009.039
1.028.259
641
S-4-12-ii
1.281.320
1.319.759
1.345.386
1.371.012
642
S-4-12-iii
2.502.519
2.577.595
2.627.645
2.677.695
643
S-4-13-i
1.281.320
1.319.759
1.345.386
1.371.012
644
S-4-13-ii
2.265.086
2.333.039
2.378.340
2.423.642
645
S-4-13-iii
4.612.003
4.750.363
4.842.604
4.934.844
646
S-4-14-i
780.685
804.105
819.719
835.333
647
S-4-14-ii
1.658.436
1.708.189
1.741.358
1.774.526
648
S-4-14-iii
3.144.986
3.239.335
3.302.235
3.365.135
649
S-4-15-i
590.439
608.152
619.961
631.770
650
S-4-15-ii
1.114.359
1.147.790
1.170.077
1.192.365
651
S-4-15-iii
1.443.354
1.486.655
1.515.522
1.544.389
652
S-4-16-i
LUKA BAKAR RINGAN
2.242.310
2.309.579
2.354.425
2.399.271
653
S-4-16-ii
LUKA BAKAR SEDANG
3.166.872
3.261.878
3.325.215
3.388.553
654
S-4-16-iii
LUKA BAKAR BERAT
5.654.941
5.824.589
5.937.688
6.050.787
1.195.643
1.231.513
1.255.426
1.279.339
1.601.650
1.649.699
1.681.732
1.713.765
655
S-4-17-i
656
S-4-17-ii

ASPIRASI RINGAN
ASPIRASI SEDANG
ASPIRASI BERAT
MAYOR RINGAN
MAYOR SEDANG
MAYOR BERAT

PASIEN RINGAN
PASIEN SEDANG
PASIEN BERAT

- 1031 No
Kode
INA-CBG
657
S-4-17-iii
658
T-1-10-i
659
T-1-10-ii
660
T-1-10-iii
661
T-4-10-i
662
T-4-10-ii
663
T-4-10-iii
664
T-4-11-i
665
T-4-11-ii
666
T-4-11-iii
667
T-4-12-i
668
T-4-12-ii
669
T-4-12-iii
670
U-1-10-i
671
672
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.611.806
2.690.160
2.742.396
2.794.632
1.234.234
1.271.261
1.295.946
1.320.630
1.657.493
1.707.217
1.740.367
1.773.517
3.015.519
3.105.985
3.166.295
3.226.606
539.889
556.086
566.884
577.681
1.028.909
1.059.776
1.080.355
1.100.933
1.495.755
1.540.627
1.570.542
1.600.457
533.919
549.937
560.615
571.294
840.237
865.444
882.249
899.054
1.353.375
1.393.976
1.421.044
1.448.111
1.121.155
1.154.790
1.177.213
1.199.636
1.694.564
1.745.401
1.779.292
1.813.183
2.636.132
2.715.216
2.767.939
2.820.662
1.193.367
1.229.168
1.253.035
1.276.902
U-1-10-ii
2.435.138
2.508.192
2.556.895
2.605.598
U-1-10-iii
10.515.418
10.830.880
11.041.188
11.251.497
5.178.149
5.333.493
5.437.056
5.540.619
6.904.198
7.111.324
7.249.408
7.387.492
11.599.668
11.947.658
12.179.651
12.411.645

DOKTER RINGAN
DOKTER SEDANG
DOKTER BERAT

LAIN-LAIN (RINGAN)
LAIN-LAIN (SEDANG)
LAIN-LAIN (BERAT)
673
U-1-11-i
674
U-1-11-ii
675
U-1-11-iii
676
U-1-12-i
3.164.423
3.259.355
3.322.644
3.385.932
677
U-1-12-ii
7.767.223
8.000.240
8.155.584
8.310.929
678
U-1-12-iii
10.085.886
10.388.463
10.590.181
10.791.899
679
U-1-13-i
3.452.099
3.555.662
3.624.704
3.693.746
680
U-1-13-ii
3.894.905
4.011.752
4.089.650
4.167.548
681
U-1-13-iii
7.510.474
7.735.789
7.885.998
8.036.208
1.904.760
1.961.903
1.999.998
2.038.093
2.337.523
2.407.649
2.454.400
2.501.150
2.770.031
2.853.132
2.908.532
2.963.933

682
U-1-14-i
683
U-1-14-ii
684
U-1-14-iii
685
U-1-15-i
1.118.738
1.152.300
1.174.675
1.197.050
686
U-1-15-ii
1.589.649
1.637.338
1.669.131
1.700.924
687
U-1-15-iii
3.132.467
3.226.441
3.289.090
3.351.739
- 1032 No
Kode
INA-CBG
688
U-1-20-i
689
U-1-20-ii
690
U-1-20-iii
691
U-1-30-i
692
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
2.893.688
2.980.499
3.038.373
3.096.246
5.150.765
5.305.288
5.408.303
5.511.318
12.707.125
13.088.339
13.342.481
13.596.624
2.482.280
2.556.748
2.606.394
2.656.039
U-1-30-ii
3.351.078
3.451.610
3.518.632
3.585.653
693
U-1-30-iii
6.569.076
6.766.148
6.897.530
7.028.911
694
U-4-10-i
2.310.588
2.379.905
2.426.117
2.472.329
695
U-4-10-ii
5.792.158
5.965.923
6.081.766
6.197.610
696
U-4-10-iii
8.449.498
8.702.983
8.871.973
9.040.963
697
U-4-11-i
1.281.320
1.319.759
1.345.386
1.371.012
698
U-4-11-ii
1.921.980
1.979.639
2.018.079
2.056.518
699
U-4-11-iii
2.658.090
2.737.833
2.790.995
2.844.157
700
U-4-12-i
1.281.320
1.319.759
1.345.386
1.371.012
701
U-4-12-ii
1.493.724
1.538.536
1.568.410
1.598.284
702
U-4-12-iii
2.374.953
2.446.202
2.493.701
2.541.200
703
U-4-13-i
1.258.802
1.296.566
1.321.742
1.346.918
704
U-4-13-ii
1.463.431
1.507.334
1.536.603
1.565.871
705
U-4-13-iii
1.661.619
1.711.468
1.744.700
1.777.932
706
U-4-14-i
1.601.650
1.649.699
1.681.732
1.713.765
707
U-4-14-ii
1.921.980
1.979.639
2.018.079
2.056.518
708
U-4-14-iii
3.219.650
3.316.239
3.380.632
3.445.025
709
U-4-15-i
1.281.320
1.319.759
1.345.386
1.371.012
710
U-4-15-ii
1.601.650
1.649.699
1.681.732
1.713.765
711
U-4-15-iii
2.242.744
2.310.027
2.354.882
2.399.736
712
V-1-10-i
3.745.723
3.858.094
3.933.009
4.007.923
713
V-1-10-ii
4.315.124
4.444.578
4.530.880
4.617.183
714
V-1-10-iii
8.198.736
8.444.698
8.608.672
8.772.647
715
V-1-11-i
4.315.124
4.444.578
4.530.880
4.617.183
716
V-1-11-ii
4.815.751
4.960.223
5.056.538
5.152.853
717
V-1-11-iii
7.131.390
7.345.331
7.487.959
7.630.587
2.330.514
2.400.429
2.447.040
2.493.650
8.906.450
9.173.643
9.351.772
9.529.901
10.399.092
10.711.065
10.919.046
11.127.028
718
V-1-12-i
719
V-1-12-ii
720
V-1-12-iii


DAN TELINGA RINGAN
DAN TELINGA SEDANG
DAN TELINGA BERAT


KOMPLEK RINGAN
KOMPLEK SEDANG
KOMPLEK BERAT

- 1033 No
Kode
INA-CBG
721
V-1-13-i
722
V-1-13-ii
723
V-1-13-iii
724
V-1-14-i
725
V-1-14-ii
726
V-1-14-iii
727
V-1-15-i
728
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
3.532.304
3.638.273
3.708.919
3.779.565
6.712.391
6.913.763
7.048.010
7.182.258
10.356.298
10.666.987
10.874.113
11.081.239
4.258.233
4.385.980
4.471.145
4.556.310
6.193.235
6.379.033
6.502.897
6.626.762
8.418.803
8.671.367
8.839.743
9.008.119
2.007.520
2.067.746
2.107.896
2.148.046
V-1-15-ii
3.823.935
3.938.653
4.015.131
4.091.610
729
V-1-15-iii
6.722.404
6.924.076
7.058.524
7.192.972
730
V-4-10-i
3.232.614
3.329.592
3.394.245
3.458.897
731
V-4-10-ii
4.175.307
4.300.566
4.384.072
4.467.578
732
V-4-10-iii
7.979.744
8.219.137
8.378.732
8.538.326
733
V-4-11-i
1.643.905
1.693.222
1.726.100
1.758.979
734
V-4-11-ii
2.402.008
2.474.068
2.522.109
2.570.149
735
V-4-11-iii
3.963.154
4.082.049
4.161.312
4.240.575
736
W-1-01-i
4.833.886
4.978.903
5.075.581
5.172.258
737
W-1-01-ii
5.822.187
5.996.852
6.113.296
6.229.740
738
W-1-01-iii
12.860.054
13.245.856
13.503.057
13.760.258
739
W-1-10-i
1.346.232
1.386.618
1.413.543
1.440.468
740
W-1-10-ii
2.512.289
2.587.658
2.637.903
2.688.149
741
W-1-10-iii
4.109.308
4.232.587
4.314.773
4.396.959
742
W-1-11-i
1.398.287
1.440.235
1.468.201
1.496.167
743
W-1-11-ii
2.696.773
2.777.676
2.831.612
2.885.547
744
W-1-11-iii
5.178.149
5.333.493
5.437.056
5.540.619
745
W-1-12-i
1.270.554
1.308.670
1.334.081
1.359.493
746
W-1-12-ii
1.444.595
1.487.933
1.516.825
1.545.717
747
W-1-12-iii
2.219.080
2.285.653
2.330.035
2.374.416
748
W-1-13-i
1.512.259
1.557.627
1.587.872
1.618.117
749
W-1-13-ii
1.641.878
1.691.134
1.723.972
1.756.809
750
W-1-13-iii
2.205.345
2.271.505
2.315.612
2.359.719
751
W-1-20-i
4.120.476
4.244.090
4.326.499
4.408.909
752
W-1-20-ii
5.796.067
5.969.949
6.085.871
6.201.792

NON KOMPLEK (BERAT)

RINGAN
SEDANG
BERAT

SERVIK RINGAN
SERVIK SEDANG
SERVIK BERAT
ENDOSKOP RINGAN
ENDOSKOP SEDANG
ENDOSKOP BERAT
- 1034 No
Kode
INA-CBG
753
W-1-20-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
BERAT
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
7.322.067
7.541.729
7.688.170
7.834.611
2.249.367
2.316.848
2.361.835
2.406.822
3.587.856
3.695.492
3.767.249
3.839.006
9.540.992
9.827.222
10.018.042
10.208.861
754
W-1-30-i
755
W-1-30-ii
756
W-1-30-iii
757
W-4-10-i
1.677.464
1.727.788
1.761.337
1.794.886
758
W-4-10-ii
2.267.280
2.335.299
2.380.644
2.425.990
759
W-4-10-iii
5.125.279
5.279.038
5.381.543
5.484.049
760
W-4-11-i
1.601.650
1.649.699
1.681.732
1.713.765
761
W-4-11-ii
2.562.640
2.639.519
2.690.772
2.742.024
762
W-4-11-iii
3.114.367
3.207.798
3.270.085
3.332.372
1.281.320
1.319.759
1.345.386
1.371.012
1.761.815
1.814.669
1.849.906
1.885.142
1.964.228
2.023.155
2.062.439
2.101.724

763
W-4-12-i
764
W-4-12-ii
765
W-4-12-iii
766
W-4-13-i
ABORTUS RINGAN
702.691
723.772
737.825
751.879
767
W-4-13-ii
ABORTUS SEDANG
960.990
989.820
1.009.039
1.028.259
768
W-4-13-iii
ABORTUS BERAT
1.281.320
1.319.759
1.345.386
1.371.012
769
W-4-14-i
960.990
989.820
1.009.039
1.028.259
770
W-4-14-ii
1.235.988
1.273.068
1.297.788
1.322.507
771
W-4-14-iii
1.555.251
1.601.909
1.633.014
1.664.119
772
W-4-15-i
801.354
825.394
841.421
857.448
773
W-4-15-ii
891.258
917.996
935.821
953.646
774
W-4-15-iii
1.234.031
1.271.052
1.295.733
1.320.414
775
W-4-16-i
960.990
989.820
1.009.039
1.028.259
776
W-4-16-ii
1.281.320
1.319.759
1.345.386
1.371.012
777
W-4-16-iii
1.746.905
1.799.312
1.834.251
1.869.189
778
W-4-17-i
784.894
808.441
824.139
839.837
779
W-4-17-ii
1.281.320
1.319.759
1.345.386
1.371.012
780
W-4-17-iii
2.424.002
2.496.722
2.545.202
2.593.682
781
Z-4-10-i
REHABILITASI RINGAN
2.198.593
2.264.551
2.308.523
2.352.495
782
Z-4-10-ii
REHABILITASI SEDANG
2.918.315
3.005.864
3.064.231
3.122.597
783
Z-4-10-iii
REHABILITASI BERAT
4.145.745
4.270.117
4.353.032
4.435.947
784
Z-4-11-i
1.919.130
1.976.704
2.015.086
2.053.469
785
Z-4-11-ii
2.310.208
2.379.514
2.425.719
2.471.923
786
Z-4-11-iii
3.655.160
3.764.815
3.837.918
3.911.021
- 1035 No
Kode
INA-CBG
787
Z-4-12-i
788
Z-4-12-ii
789
Z-4-12-iii
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
960.990
989.820
1.009.039
1.028.259
1.957.985
2.016.725
2.055.884
2.095.044
2.488.289
2.562.938
2.612.704
2.662.469
No
Kode
INA-CBG
B-2-10-0
B-2-11-0
B-2-12-0
B-2-13-0
B-2-14-0
B-3-10-0
B-3-11-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
749.845
772.341
787.338
802.335
972.667
1.001.847
1.021.300
1.040.753
1.808.802
1.863.066
1.899.242
1.935.418
1.494.799
1.539.643
1.569.539
1.599.435
1.248.776
1.286.239
1.311.215
1.336.190
437.826
450.961
459.718
468.474
976.295
1.005.584
1.025.110
1.044.636
B-3-12-0

200.597
206.615
210.627
214.638
C-3-10-0
547.199
563.615
574.559
585.503
10
C-3-11-0

KANDUNG KEMIH
865.416
891.379
908.687
925.995
11
C-3-12-0
196.188
202.074
205.997
209.921
190.512
196.227
200.038
203.848
1.621.832
1.670.487
1.702.924
1.735.360
1.486.474
1.531.068
1.560.797
1.590.527

LAPAROSKOPI
PANKREAS
LAPAROSKOPI
EMPEDU

OVARIUM
GASTROINTESTINAL
GINJAL ATAU PROSTAT
12
C-3-13-0
13
C-3-14-0
14
C-3-15-0
15
C-3-16-0
337.096
347.209
353.951
360.693
16
C-3-17-0

LEHER
223.620
230.328
234.801
239.273
17
C-3-18-0
99.143
102.118
104.101
106.083
18
C-3-19-0

MYELOMA ATAU TESTIS
140.209
144.415
147.219
150.024
19
C-3-20-0
2.792.265
2.876.033
2.931.878
2.987.724
20
C-3-21-0
160.003
164.804
168.004
171.204
21
C-3-22-0
702.500
723.575
737.625
751.675
22
C-3-23-0
113.790
117.203
119.479
121.755
23
D-2-10-0

TULANG
964.042
992.964
1.012.244
1.031.525
24
D-2-11-0
PROSEDUR LIMPA
1.207.146
1.243.360
1.267.503
1.291.646
25
D-2-21-0
1.012.453
1.042.827
1.063.076
1.083.325
26
D-2-22-0
222.203
228.869
233.313
237.757
27
D-3-10-0
160.947
165.776
168.995
172.213
28
D-3-11-0
417.865
430.401
438.758
447.116
29
E-2-10-0
247.874
255.311
260.268
265.226
30
E-2-21-0
179.700
185.092
188.686
192.280
31
E-2-22-0
179.700
185.092
188.686
192.280

TYMUS
TYMUS
TULANG
PEMBENTUK DARAH
PARATIROID
THYROGLOSSAL
- 1037 No
Kode
INA-CBG
32
E-3-10-0
33
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

ENDOKRIN
208.980
215.249
219.429
223.609
F-3-10-0
TERAPI SHOCK
291.520
300.266
306.096
311.927
34
F-5-10-0
357.207
367.923
375.067
382.211
35
F-5-11-0
TERAPI KELOMPOK
235.545
242.611
247.322
252.033
36
F-5-12-0
301.420
310.463
316.491
322.519
37
F-5-13-0
255.283
262.941
268.047
273.152
38
F-5-14-0
171.261
176.398
179.824
183.249
39
F-5-15-0
160.664
165.484
168.698
171.911
40
F-5-16-0
167.347
172.368
175.715
179.062
41
G-2-10-0
140.919
145.147
147.965
150.784
42
G-2-11-0
1.221.549
1.258.195
1.282.626
1.307.057
43
G-2-12-0

EKSTRAKRANIAL
1.770.325
1.823.434
1.858.841
1.894.247
44
G-2-13-0
434.300
447.329
456.015
464.701
45
G-2-21-0
792.090
815.853
831.695
847.537
46
G-2-22-0
718.889
740.456
754.834
769.211
47
G-2-31-0
1.186.230
1.221.817
1.245.541
1.269.266
48
G-2-32-0
608.060
626.302
638.463
650.625
49
G-3-10-0
241.343
248.583
253.410
258.237
50
G-3-11-0
321.423
331.065
337.494
343.922
51
G-3-12-0
526.657
542.456
552.989
563.522
52
G-3-13-0
526.717
542.518
553.052
563.587
53
H-2-21-0
691.237
711.974
725.799
739.624
54
H-2-22-0
179.700
185.092
188.686
192.280
55
H-2-23-0
179.700
185.092
188.686
192.280
56
H-2-31-0
1.144.977
1.179.326
1.202.226
1.225.126
57
H-2-32-0
119.165
122.740
125.124
127.507
58
H-2-33-0
179.700
185.092
188.686
192.280
59
H-2-34-0
513.665
529.075
539.348
549.621
60
H-2-35-0
169.264
174.342
177.727
181.113
61
H-2-36-0
913.648
941.058
959.331
977.604
62
H-2-37-0

972.619
1.001.797
1.021.250
1.040.702
63
H-3-10-0
338.400
348.552
355.320
362.088
64
H-3-11-0
177.961
183.300
186.859
190.418

AKUT
MENTAL
PROSEDUR KRANIOTOMI

MATA
MATA
MATA
MATA
MATA
- 1038 No
Kode
INA-CBG
65
H-3-12-0
66
H-3-13-0
67
I-2-11-0
68
I-2-12-0
69
I-2-13-0
70
I-2-14-0
71
I-2-15-0
Deskripsi (INA-CBG)
MATA
TORASIK
ABDOMEN
PENGGANTIAN ALAT
DARAH VENA
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
185.800
191.374
195.090
198.806
180.401
185.813
189.421
193.029
2.080.408
2.142.820
2.184.428
2.226.036
1.462.754
1.506.636
1.535.891
1.565.147
1.859.072
1.914.844
1.952.026
1.989.207
3.290.162
3.388.866
3.454.670
3.520.473
197.864
203.800
207.757
211.714
2.078.153
2.140.498
2.182.061
2.223.624
685.107
705.661
719.363
733.065
72
I-2-16-0
73
I-2-17-0
74
I-2-21-0
1.604.039
1.652.160
1.684.241
1.716.322
75
I-2-22-0
1.510.484
1.555.798
1.586.008
1.616.217
76
I-2-23-0
309.116
318.389
324.572
330.754
77
I-2-31-0
2.404.099
2.476.222
2.524.304
2.572.386
78
I-2-32-0
3.143.712
3.238.024
3.300.898
3.363.772
79
I-2-41-0
2.107.898
2.171.135
2.213.293
2.255.451
80
I-2-42-0

LAIN
2.450.780
2.524.303
2.573.319
2.622.335
81
I-3-10-0
PROSEDUR RESUSITASI
311.105
320.438
326.660
332.882
82
I-3-11-0
164.200
169.126
172.410
175.694
83
I-3-12-0
954.271
982.899
1.001.984
1.021.070
84
I-3-13-0
313.419
322.822
329.090
335.359
85
I-3-14-0
200.891
206.918
210.936
214.954
177.961
183.300
186.859
190.418
1.101.820
1.134.875
1.156.911
1.178.948
177.613
182.942
186.494
190.046
895.060
921.912
939.813
957.714
1.160.973
1.195.802
1.219.021
1.242.241

PACU JANTUNG

KARDIOVASKULAR
PERNAFASAN
PENDEK
86
I-3-15-0
87
J-2-10-0
88
J-2-21-0
89
J-2-22-0
90
J-2-31-0
PROSEDUR
91
J-2-32-0
863.956
889.875
907.154
924.433
92
J-3-10-0
179.700
185.092
188.686
192.280
93
J-3-11-0

PADA DADA
507.802
523.036
533.192
543.348
94
J-3-12-0
196.188
202.074
205.997
209.921
95
J-3-13-0
288.740
297.402
303.177
308.952
96
J-3-14-0
306.529
315.725
321.855
327.986
- 1039 No
Kode
INA-CBG
97
J-3-15-0
98
J-3-16-0
99
J-3-17-0
100
K-2-10-0
101
K-2-11-0
102
K-2-12-0

103
K-2-13-0
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
268.801
276.865
282.241
287.617
306.529
315.725
321.855
327.986
179.700
185.092
188.686
192.280
517.240
532.757
543.102
553.446
1.104.517
1.137.653
1.159.743
1.181.834
847.860
873.295
890.253
907.210
1.379.937
1.421.336
1.448.934
1.476.533
179.700
185.092
188.686
192.280
179.700
185.092
188.686
192.280
2.309.579
2.378.867
2.425.058
2.471.250
776.594
799.892
815.424
830.956
179.700
185.092
188.686
192.280

PERNAFASAN
KECIL

FEMORALIS
USUS BESAR
ATAS
ATAS
104
K-2-14-0
105
K-2-21-0
106
K-2-22-0
107
K-2-31-0
108
K-2-32-0
109
K-2-41-0
855.435
881.098
898.206
915.315
110
K-2-42-0

244.408
251.740
256.629
261.517
111
K-2-51-0
566.863
583.869
595.206
606.543
112
K-2-52-0
309.116
318.389
324.572
330.754
113
K-2-53-0
179.700
185.092
188.686
192.280
114
K-3-10-0

GASTROINTESTINAL
341.958
352.217
359.056
365.895
115
K-3-11-0
205.584
211.751
215.863
219.974
116
K-3-12-0
208.488
214.742
218.912
223.082
117
K-3-13-0
179.700
185.092
188.686
192.280
481.601
496.049
505.681
515.313
232.572
239.549
244.201
248.852
308.173
317.418
323.581
329.745
1.059.509
1.091.294
1.112.484
1.133.674
679.138
699.512
713.095
726.677
306.529
315.725
321.855
327.986
309.116
318.389
324.572
330.754

GASTROINTESTINAL
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
LUKA BAKAR
118
K-3-14-0
119
K-3-15-0
120
K-3-16-0
121
L-2-21-0
122
L-2-22-0
123
L-2-31-0
124
L-2-32-0
125
L-2-41-0
925.611
953.379
971.892
990.404
126
L-2-42-0

207.600
213.828
217.980
222.132
127
L-2-51-0
1.385.785
1.427.358
1.455.074
1.482.790
L-2-52-0

1.060.171
1.091.976
1.113.180
1.134.383
128
- 1040 No
Kode
INA-CBG
129
L-2-53-0
130
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4

179.700
185.092
188.686
192.280
L-3-10-0
244.408
251.740
256.629
261.517
131
L-3-11-0
237.337
244.457
249.204
253.951
132
L-3-12-0
180.755
186.178
189.793
193.408
133
M-2-10-0
1.417.759
1.460.291
1.488.647
1.517.002
134
M-2-21-0
1.269.701
1.307.792
1.333.186
1.358.580
135
M-2-22-0
309.116
318.389
324.572
330.754
136
M-2-31-0
PROSEDUR BUNION
771.216
794.352
809.777
825.201
137
M-2-32-0
244.408
251.740
256.629
261.517
138
M-2-41-0

TULANG
244.408
251.740
256.629
261.517
139
M-2-42-0
84.230
86.757
88.441
90.126
140
M-2-51-0
179.700
185.092
188.686
192.280
141
M-2-52-0
179.700
185.092
188.686
192.280
142
M-2-61-0
PROSEDUR ARTROSKOPI
880.806
907.230
924.847
942.463
143
M-2-62-0
179.700
185.092
188.686
192.280
885.571
912.138
929.850
947.561
1.207.736
1.243.968
1.268.123
1.292.277
179.700
185.092
188.686
192.280
891.627
918.375
936.208
954.040
860.458
886.271
903.481
920.690

DAN WAJAH
PAHA
PAHA

TULANG
WAJAH
WAJAH
BAWAH
BAWAH
144
M-2-63-0
145
M-2-64-0
146
M-2-65-0
147
M-2-71-0
148
M-2-72-0
149
M-2-81-0
1.283.126
1.321.619
1.347.282
1.372.944
150
M-2-82-0
932.108
960.072
978.714
997.356
151
M-2-83-0
179.700
185.092
188.686
192.280
152
M-2-84-0
179.700
185.092
188.686
192.280
153
M-3-10-0
512.900
528.287
538.545
548.803
154
M-3-11-0
284.372
292.903
298.590
304.278
155
M-3-12-0
643.085
662.377
675.239
688.101
156
M-3-13-0
209.663
215.953
220.146
224.339
157
M-3-14-0

TERTUTUP
358.350
369.100
376.267
383.434
158
M-3-15-0
157.875
162.611
165.769
168.926
159
M-3-16-0

179.700
185.092
188.686
192.280
160
M-3-17-0
196.188
202.074
205.997
209.921
161
N-2-11-0
2.374.020
2.445.241
2.492.721
2.540.201

PERGELANGAN TANGAN
PERGELANGAN TANGAN
MUSKULOSKELETAL
SKELETAL
- 1041 No
Kode
INA-CBG
162
N-2-12-0
163
N-2-21-0
164
N-2-22-0
165
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
1.373.347
1.414.548
1.442.014
1.469.481
1.366.108
1.407.091
1.434.413
1.461.736
309.116
318.389
324.572
330.754
N-2-23-0
309.116
318.389
324.572
330.754
166
N-2-24-0
998.959
1.028.928
1.048.907
1.068.886
167
N-2-31-0
840.961
866.190
883.010
899.829
168
N-2-32-0
309.116
318.389
324.572
330.754
169
N-2-41-0
309.116
318.389
324.572
330.754
170
N-2-42-0
522.774
538.457
548.913
559.368
171
N-3-10-0
309.116
318.389
324.572
330.754
172
N-3-11-0
358.155
368.900
376.063
383.226
173
N-3-12-0
276.762
285.065
290.600
296.135
174
N-3-13-0
309.116
318.389
324.572
330.754
175
N-3-14-0
265.977
273.957
279.276
284.596
176
N-3-15-0
682.033
702.494
716.135
729.775
177
O-7-10-0
113.870
117.286
119.564
121.841
178
O-7-11-0
627.113
645.926
658.469
671.011
179
O-7-12-0
228.353
235.204
239.771
244.338
180
O-7-13-0
126.909
130.716
133.254
135.792
181
P-9-10-0
169.264
174.342
177.727
181.113
182
P-9-11-0
169.264
174.342
177.727
181.113
183
P-9-12-0
169.264
174.342
177.727
181.113
184
P-9-13-0
169.264
174.342
177.727
181.113
185
P-9-14-0
169.264
174.342
177.727
181.113
186
P-9-15-0
107.893
111.129
113.287
115.445
187
P-9-16-0
169.264
174.342
177.727
181.113
188
P-9-17-0
168.536
173.592
176.963
180.334
189
Q-5-10-0
220.605
227.223
231.635
236.048
190
Q-5-11-0
165.338
170.298
173.604
176.911
191
Q-5-12-0
GIGI
145.724
150.096
153.010
155.925
192
Q-5-13-0
MEDICAL CHECK-UP
110.744
114.066
116.281
118.496
193
Q-5-14-0
121.855
125.510
127.947
130.384


DAN URETHRA
DAN URETHRA
TRANSURETHRA
TRANSURETHRA
SALURAN KEMIH
KEMIH
KEMIH
PROSEDUR DIALISIS
CAESAR
VAGINAL/JALAN LAHIR

ASPIRASI
- 1042 No
Kode
INA-CBG
194
Q-5-15-0
195
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
83.799
86.313
87.989
89.665
Q-5-16-0
VAKSINASI
94.713
97.554
99.448
101.342
196
Q-5-17-0
PASANG INFUS
81.924
84.382
86.020
87.659
197
Q-5-18-0
154.206
158.833
161.917
165.001
198
Q-5-19-0
172.394
177.565
181.013
184.461
199
Q-5-20-0
ABORSI MENGANCAM
115.550
119.016
121.327
123.638
200
Q-5-21-0
ABORSI
113.976
117.395
119.675
121.954
201
Q-5-22-0
121.855
125.510
127.947
130.384
202
Q-5-23-0
149.182
153.658
156.641
159.625
203
Q-5-24-0
101.889
104.946
106.984
109.022
204
Q-5-25-0
158.894
163.661
166.839
170.017
205
Q-5-26-0
BRONKIAL AKUT
224.904
231.651
236.149
240.647
206
Q-5-27-0
160.053
164.854
168.055
171.256
207
Q-5-28-0
129.879
133.775
136.372
138.970
208
Q-5-29-0

JANTUNG LAIN-LAIN
367.708
378.739
386.093
393.447
209
Q-5-30-0
426.133
438.917
447.440
455.963
210
Q-5-31-0
FRAKTUR
152.027
156.588
159.629
162.669
211
Q-5-32-0
SALURAN KEMIH AKUT
176.082
181.364
184.886
188.408
212
Q-5-33-0
HEMATOLOGI AKUT
184.357
189.888
193.575
197.262
213
Q-5-34-0
INFEKSI VIRUS HIV
261.892
269.749
274.987
280.225
214
Q-5-35-0
INFEKSI AKUT
296.979
305.888
311.828
317.767
215
Q-5-36-0
345.851
356.226
363.143
370.060
216
Q-5-37-0

SHOCK
176.402
181.694
185.222
188.750
217
Q-5-38-0
PARU AKUT
235.237
242.294
246.999
251.704
218
Q-5-39-0
150.534
155.051
158.061
161.072
219
Q-5-40-0
147.698
152.129
155.083
158.037
220
Q-5-41-0
204.468
210.602
214.691
218.780
221
Q-5-42-0
160.311
165.120
168.326
171.532
222
Q-5-43-0
230.857
237.782
242.400
247.017
223
Q-5-44-0
188.411
194.063
197.832
201.600
224
T-2-10-0

TERAPI DETOKSIKASI
97.726
100.657
102.612
104.566
225
U-2-10-0
1.304.259
1.343.387
1.369.472
1.395.557
226
U-2-11-0

LEHER
1.550.257
1.596.765
1.627.770
1.658.775
227
U-2-12-0
170.569
175.686
179.097
182.509
- 1043 No
Kode
INA-CBG
228
U-2-13-0
229
Deskripsi (INA-CBG)
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
223.620
230.328
234.801
239.273
U-2-14-0
415.384
427.846
436.153
444.461
230
U-2-15-0
236.012
243.093
247.813
252.533
231
U-2-21-0
274.917
283.165
288.663
294.162
232
U-2-22-0
531.163
547.097
557.721
568.344
233
U-2-23-0
695.995
716.874
730.794
744.714
234
U-2-24-0
586.572
604.169
615.901
627.632
235
U-2-25-0
223.620
230.328
234.801
239.273
236
U-2-31-0
179.700
185.092
188.686
192.280
237
U-2-32-0
223.620
230.328
234.801
239.273
238
U-3-10-0
213.792
220.206
224.482
228.758
239
U-3-11-0
226.981
233.790
238.330
242.869
240
U-3-12-0
100.371
103.382
105.389
107.397
241
U-3-13-0
220.622
227.241
231.654
236.066
242
U-3-14-0
202.707
208.788
212.842
216.896
243
U-3-15-0
176.778
182.082
185.617
189.153
244
U-3-16-0
PROSEDUR PADA GIGI
199.374
205.355
209.342
213.330
245
V-2-10-0

PROSTAT
1.945.121
2.003.474
2.042.377
2.081.279
246
V-2-11-0
219.360
225.941
230.328
234.715
700.009
721.010
735.010
749.010
309.116
318.389
324.572
330.754
309.116
318.389
324.572
330.754

(RHINOPLASTY)

RONGGA HIDUNG
TENGGOROKAN
PROSEDUR PADA PENIS

SKROTUM
SKROTUM
TRANSURETHRAL
247
V-2-12-0
248
V-2-13-0
249
V-2-14-0
250
V-2-15-0
SIRKUMSISI/SUNAT
169.264
174.342
177.727
181.113
251
V-3-10-0
353.012
363.602
370.662
377.723
252
V-3-11-0
746.803
769.207
784.143
799.079
253
V-3-12-0
431.149
444.083
452.706
461.329
254
W-2-10-0
157.875
162.611
165.769
168.926
255
W-2-11-0
403.469
415.573
423.643
431.712
256
W-2-12-0
746.803
769.207
784.143
799.079
257
W-2-13-0
119.774
123.367
125.763
128.158
258
W-2-21-0
1.501.273
1.546.311
1.576.336
1.606.362
259
W-2-22-0
157.875
162.611
165.769
168.926

PROSEDUR ABORSI
RAHIM & LEHER RAHIM
TERHALANG/TERGANGGU
TERHALANG/TERGANGGU
PANGGUL TERBUKA
PANGGUL TERBUKA
- 1044 No
Kode
INA-CBG
260
W-2-23-0
Deskripsi (INA-CBG)
JALAN LAHIR
Tarif INA-CBG (Rp)

Regional 1
Regional 2
Regional 3
Regional 4
526.836
542.641
553.178
563.715
1.729.443
1.781.326
1.815.915
1.850.504
1.212.937
1.249.325
1.273.584
1.297.842
261
W-2-31-0
262
W-2-32-0
263
W-2-33-0
515.514
530.980
541.290
551.600
264
W-2-34-0
175.335
180.595
184.102
187.609
265
W-3-10-0
426.133
438.917
447.440
455.962
266
W-3-11-0
340.638
350.858
357.670
364.483
267
W-3-12-0
157.875
162.611
165.769
168.926
268
Z-3-10-0
1.787.354
1.840.975
1.876.722
1.912.469
269
Z-3-11-0

EMPEDU
1.366.108
1.407.091
1.434.413
1.461.736
270
Z-3-12-0
228.107
234.950
239.512
244.074
271
Z-3-13-0

LAIN-LAIN
1.391.971
1.433.731
1.461.570
1.489.409
272
Z-3-14-0
DIAGNOSTIK TIDUR
275.236
283.493
288.998
294.502
273
Z-3-15-0
179.700
185.092
188.686
192.280
274
Z-3-16-0

(MRI)
576.784
594.088
605.623
617.159
275
Z-3-17-0
PENGOBATAN NUKLIR
242.146
249.411
254.254
259.097
276
Z-3-18-0
CT-SCAN KEPALA
233.303
240.302
244.969
249.635
277
Z-3-19-0
CT SCAN LAIN-LAIN
242.823
250.108
254.965
259.821
278
Z-3-20-0
165.150
170.105
173.408
176.711
279
Z-3-21-0
157.875
162.611
165.769
168.926
280
Z-3-22-0
177.990
183.329
186.889
190.449
281
Z-3-23-0
185.392
190.953
194.661
198.369
282
Z-3-24-0
364.258
375.186
382.471
389.756
283
Z-3-25-0
162.240
167.107
170.352
173.597
284
Z-3-26-0
183.363
188.864
192.531
196.199
285
Z-3-27-0
PERAWATAN LUKA
175.062
180.314
183.815
187.316
286
Z-3-28-0
IMAGING PAYUDARA
179.700
185.092
188.686
192.280
287
Z-3-29-0
IMAGING LAIN-LAIN
517.929
533.467
543.826
554.184
288
Z-3-30-0
FOTOTERAPI
87.407
90.029
91.778
93.526
- 1045 VI.
TARIF INA-CBG RUMAH SAKIT UMUM PUSAT NASIONAL

DR. CIPTO MANGUNKUSUMO TAHUN 2012
a. RawatInap
No
Kode
INA-CBG
A-4-10-i
SEPTIKEMIA RINGAN
4.230.985
A-4-10-ii
SEPTIKEMIA SEDANG
7.231.133
A-4-10-iii
SEPTIKEMIA BERAT
11.026.145
A-4-11-i
11.352.912
A-4-11-ii
17.538.937
A-4-11-iii
28.689.869
A-4-12-i
DEMAM RINGAN
4.331.416
A-4-12-ii
DEMAM SEDANG
6.387.653
A-4-12-iii
DEMAM BERAT
7.310.200
10
A-4-13-i
5.414.270
11
A-4-13-ii
6.497.123
12
A-4-13-iii
7.896.486
13
A-4-14-i
PENYAKIT INFEKSI BAKTERI DAN PARASIT LAIN-LAIN RINGAN
4.331.416
14
A-4-14-ii
PENYAKIT INFEKSI BAKTERI DAN PARASIT LAIN-LAIN SEDANG
6.353.383
15
A-4-14-iii
PENYAKIT INFEKSI BAKTERI DAN PARASIT LAIN-LAIN BERAT
7.090.190
16
A-4-15-i
INFEKSI HIV RINGAN
6.497.123
17
A-4-15-ii
INFEKSI HIV SEDANG
9.745.685
18
A-4-15-iii
INFEKSI HIV BERAT
13.936.136
19
B-1-01-i
72.030.742
20
B-1-01-ii
79.469.166
21
B-1-01-iii
139.405.271
22
B-1-10-i
9.338.541
23
B-1-10-ii
23.799.101
24
B-1-10-iii
42.592.883
25
B-1-11-i
PROSEDUR SALURAN EMPEDU KOMPLEK (RINGAN)
6.564.127
26
B-1-11-ii
PROSEDUR SALURAN EMPEDU KOMPLEK (SEDANG)
16.476.579
27
B-1-11-iii
PROSEDUR SALURAN EMPEDU KOMPLEK (BERAT)
20.657.541
28
B-1-12-i
PROSEDUR CHOLESISTEKTOMI TANPA LAPAROSKOPIK RINGAN
14.001.520
29
B-1-12-ii
PROSEDUR CHOLESISTEKTOMI TANPA LAPAROSKOPIK SEDANG
30.008.682
30
B-1-12-iii
PROSEDUR CHOLESISTEKTOMI TANPA LAPAROSKOPIK BERAT
36.521.698
31
B-1-13-i
PROSEDUR PANKREAS DAN HEPATOBILLIARI LAIN-LAIN (RINGAN)
Deskripsi (INA-CBG)
Tarif
INA-CBG
9.174.884
- 1046 No
Kode
INA-CBG
32
B-1-13-ii
PROSEDUR PANKREAS DAN HEPATOBILLIARI LAIN-LAIN (SEDANG)
14.944.555
33
B-1-13-iii
PROSEDUR PANKREAS DAN HEPATOBILLIARI LAIN-LAIN (BERAT)
22.032.468
34
B-1-14-i
PROSEDUR CHOLESISTEKTOMI DENGAN LAPAROSKOPIK RINGAN
12.458.848
35
B-1-14-ii
PROSEDUR CHOLESISTEKTOMI DENGAN LAPAROSKOPIK SEDANG
13.856.753
36
B-1-14-iii
PROSEDUR CHOLESISTEKTOMI DENGAN LAPAROSKOPIK BERAT
21.677.242
37
B-4-10-i
3.485.796
38
B-4-10-ii
5.414.270
39
B-4-10-iii
8.511.186
40
B-4-11-i
TUMOR SISTEM HEPATOBILLIARI DAN PANCREAS RINGAN
8.416.018
41
B-4-11-ii
TUMOR SISTEM HEPATOBILLIARI DAN PANCREAS SEDANG
12.794.449
42
B-4-11-iii
TUMOR SISTEM HEPATOBILLIARI DAN PANCREAS BERAT
13.780.066
43
B-4-12-i
GANGGUAN PANKREAS SELAIN TUMOR (RINGAN)
7.384.479
44
B-4-12-ii
GANGGUAN PANKREAS SELAIN TUMOR (SEDANG)
10.469.374
45
B-4-12-iii
GANGGUAN PANKREAS SELAIN TUMOR (BERAT)
19.896.802
46
B-4-13-i
GANGGUAN HATI SELAIN TUMOR, SIROSIS ATAU HEPATITIS ALKOHOLIK RINGAN
6.497.123
47
B-4-13-ii
GANGGUAN HATI SELAIN TUMOR, SIROSIS ATAU HEPATITIS ALKOHOLIK SEDANG
7.579.977
48
B-4-13-iii
GANGGUAN HATI SELAIN TUMOR, SIROSIS ATAU HEPATITIS ALKOHOLIK BERAT
49
B-4-14-i
GANGGUAN SALURAN EMPEDU LAIN-LAIN RINGAN
6.497.123
50
B-4-14-ii
GANGGUAN SALURAN EMPEDU LAIN-LAIN SEDANG
7.579.977
51
B-4-14-iii
GANGGUAN SALURAN EMPEDU LAIN-LAIN BERAT
52
C-4-10-i
6.505.287
53
C-4-10-ii
12.639.091
54
C-4-10-iii
LEUKEMIA AKUT BERAT
20.574.224
55
C-4-11-i
6.544.297
56
C-4-11-ii
8.662.831
57
C-4-11-iii
58
C-4-12-i
RADIOTERAPI RINGAN
4.331.416
59
C-4-12-ii
RADIOTERAPI SEDANG
12.261.966
60
C-4-12-iii
RADIOTERAPI BERAT
24.894.249
61
C-4-13-i
KEMOTERAPI RINGAN
4.331.416
62
C-4-13-ii
KEMOTERAPI SEDANG
8.662.831
63
C-4-13-iii
KEMOTERAPI BERAT
64
C-4-14-i
TUMOR MYELOPROLIFERATIF LAIN-LAIN RINGAN
5.775.062
65
C-4-14-ii
TUMOR MYELOPROLIFERATIF LAIN-LAIN SEDANG
8.438.890
Deskripsi (INA-CBG)
Tarif
INA-CBG
13.690.301
10.112.452
15.143.111
11.334.674
- 1047 No
Kode
INA-CBG
66
C-4-14-iii
TUMOR MYELOPROLIFERATIF LAIN-LAIN BERAT
12.864.844
67
D-1-10-i
PROSEDUR PENCANGKOKAN SUMSUM TULANG RINGAN
46.091.399
68
D-1-10-ii
PROSEDUR PENCANGKOKAN SUMSUM TULANG SEDANG
70.200.737
69
D-1-10-iii
PROSEDUR PENCANGKOKAN SUMSUM TULANG BERAT
95.141.180
70
D-1-11-i
9.740.823
71
D-1-11-ii
25.405.853
72
D-1-11-iii
35.008.769
73
D-1-20-i
PROSEDUR PADA DARAH DAN ORGAN PEMBENTUK DARAH LAIN-LAIN (RINGAN)
11.669.590
74
D-1-20-ii
PROSEDUR PADA DARAH DAN ORGAN PEMBENTUK DARAH LAIN-LAIN (SEDANG)
26.256.577
75
D-1-20-iii
PROSEDUR PADA DARAH DAN ORGAN PEMBENTUK DARAH LAIN-LAIN (BERAT)
48.801.437
76
D-4-10-i
4.160.591
77
D-4-10-ii
8.401.015
78
D-4-10-iii
79
D-4-11-i
6.009.625
80
D-4-11-ii
10.849.527
81
D-4-11-iii
16.395.076
82
D-4-12-i
5.554.008
83
D-4-12-ii
7.703.954
84
D-4-12-iii
85
D-4-13-i
GANGGUAN SEL DARAH MERAH SELAIN KRISIS ANEMIA SEL SICKLE RINGAN
4.331.416
86
D-4-13-ii
GANGGUAN SEL DARAH MERAH SELAIN KRISIS ANEMIA SEL SICKLE SEDANG
6.497.123
87
D-4-13-iii
GANGGUAN SEL DARAH MERAH SELAIN KRISIS ANEMIA SEL SICKLE BERAT
7.579.977
88
D-4-14-i
GANGGUAN PADA DARAH & ORGAN PEMBENTUK DARAH LAIN-LAIN (RINGAN)
5.365.984
89
D-4-14-ii
GANGGUAN PADA DARAH & ORGAN PEMBENTUK DARAH LAIN-LAIN (SEDANG)
12.184.686
90
D-4-14-iii
GANGGUAN PADA DARAH & ORGAN PEMBENTUK DARAH LAIN-LAIN (BERAT)
14.534.644
91
E-1-01-i
PROSEDUR KELENJAR PITUITARI DAN PINEAL RINGAN
10.675.629
92
E-1-01-ii
PROSEDUR KELENJAR PITUITARI DAN PINEAL SEDANG
13.984.058
93
E-1-01-iii
PROSEDUR KELENJAR PITUITARI DAN PINEAL BERAT
30.825.985
94
E-1-10-i
10.579.579
95
E-1-10-ii
12.841.126
96
E-1-10-iii
27.065.314
97
E-1-20-i
PROSEDUR PADA TIROID, PARATIROID DAN SALURAN TIROGLOSAL RINGAN
12.596.827
98
E-1-20-ii
PROSEDUR PADA TIROID, PARATIROID DAN SALURAN TIROGLOSAL SEDANG
16.871.414
99
E-1-20-iii
PROSEDUR PADA TIROID, PARATIROID DAN SALURAN TIROGLOSAL BERAT
37.382.286
Deskripsi (INA-CBG)
Tarif
INA-CBG
10.828.539
11.829.426
- 1048 No
Kode
INA-CBG
100
E-4-10-i
PENYAKIT KENCING MANIS & GANGGUAN NUTRISI/ METABOLIK RINGAN
5.414.270
101
E-4-10-ii
PENYAKIT KENCING MANIS & GANGGUAN NUTRISI/ METABOLIK SEDANG
7.917.356
102
E-4-10-iii
PENYAKIT KENCING MANIS & GANGGUAN NUTRISI/ METABOLIK BERAT
103
E-4-11-i
HIPOVOLEMIA & GANGGUAN ELEKROLIT RINGAN
4.749.761
104
E-4-11-ii
HIPOVOLEMIA & GANGGUAN ELEKROLIT SEDANG
8.985.733
105
E-4-11-iii
HIPOVOLEMIA & GANGGUAN ELEKROLIT BERAT
106
E-4-12-i
5.675.301
107
E-4-12-ii
9.745.685
108
E-4-12-iii
109
E-4-13-i
GANGGUAN KELENJAR ENDOKRIN LAIN-LAIN RINGAN
5.986.332
110
E-4-13-ii
GANGGUAN KELENJAR ENDOKRIN LAIN-LAIN SEDANG
10.278.574
111
E-4-13-iii
GANGGUAN KELENJAR ENDOKRIN LAIN-LAIN BERAT
17.784.529
112
F-4-10-i
SCHIZOFRENIA RINGAN
7.319.423
113
F-4-10-ii
SCHIZOFRENIA SEDANG
8.128.455
114
F-4-10-iii
SCHIZOFRENIA BERAT
115
F-4-11-i
6.746.735
116
F-4-11-ii
7.860.587
117
F-4-11-iii
DEPRESI MAYOR BERAT
118
F-4-12-i
GANGGUAN PERSONALITI & KONTROL IMPULSE RINGAN
3.294.666
119
F-4-12-ii
GANGGUAN PERSONALITI & KONTROL IMPULSE SEDANG
4.638.485
120
F-4-12-iii
GANGGUAN PERSONALITI & KONTROL IMPULSE BERAT
121
F-4-13-i
5.452.387
122
F-4-13-ii
7.220.362
123
F-4-13-iii
9.309.735
124
F-4-14-i
DEPRESI RINGAN
3.816.671
125
F-4-14-ii
DEPRESI SEDANG
4.895.655
126
F-4-14-iii
DEPRESI BERAT
6.587.322
127
F-4-15-i
4.537.804
128
F-4-15-ii
6.497.123
129
F-4-15-iii
8.557.110
130
F-4-16-i
GANGGUAN ORGANIK DAN KETERBELAKANGAN MENTAL RINGAN
9.773.543
131
F-4-16-ii
GANGGUAN ORGANIK DAN KETERBELAKANGAN MENTAL SEDANG
11.361.499
132
F-4-16-iii
GANGGUAN ORGANIK DAN KETERBELAKANGAN MENTAL BERAT
15.165.705
133
F-4-17-i
GANGGUAN MENTAL PADA KANAK-KANAK RINGAN
Deskripsi (INA-CBG)
Tarif
INA-CBG
14.718.840
14.817.888
15.657.602
12.034.357
10.080.145
10.062.416
2.194.711
- 1049 No
Kode
INA-CBG
134
F-4-17-ii
GANGGUAN MENTAL PADA KANAK-KANAK SEDANG
6.432.488
135
F-4-17-iii
GANGGUAN MENTAL PADA KANAK-KANAK BERAT
6.862.992
136
F-4-18-i
8.471.378
137
F-4-18-ii
9.320.908
138
F-4-18-iii
139
F-4-19-i
6.496.747
140
F-4-19-ii
8.319.252
141
F-4-19-iii
10.357.580
142
G-1-01-i
PROSEDUR PADA PEMBULUH DARAH INTRA KRANIAL RINGAN
20.088.117
143
G-1-01-ii
PROSEDUR PEMBULUH DARAH INTRA KRANIAL SEDANG
34.001.560
144
G-1-01-iii
PROSEDUR PEMBULUH DARAH INTRA KRANIAL BERAT
65.823.222
145
G-1-10-i
18.600.000
146
G-1-10-ii
21.429.462
147
G-1-10-iii
23.226.263
148
G-1-11-i
11.890.194
149
G-1-11-ii
24.417.410
150
G-1-11-iii
51.127.836
151
G-1-12-i
PROSEDUR PEMBULUH DARAH EXTRA KRANIAL RINGAN
9.247.068
152
G-1-12-ii
PROSEDUR PEMBULUH DARAH EXTRA KRANIAL SEDANG
21.170.241
153
G-1-12-iii
PROSEDUR PEMBULUH DARAH EXTRA KRANIAL BERAT
37.339.663
154
G-1-13-i
2.371.861
155
G-1-13-ii
6.370.556
156
G-1-13-iii
14.374.657
157
G-1-20-i
PROSEDUR SARAF KRANIAL DAN PERIFER RINGAN
11.652.092
158
G-1-20-ii
PROSEDUR SARAF KRANIAL DAN PERIFER SEDANG
15.742.359
159
G-1-20-iii
PROSEDUR SARAF KRANIAL DAN PERIFER BERAT
38.543.313
160
G-1-30-i
14.861.195
161
G-1-30-ii
38.789.143
162
G-1-30-iii
49.933.614
163
G-4-10-i
KECEDERAAN & GANGGUAN TULANG BELAKANG RINGAN
6.497.123
164
G-4-10-ii
KECEDERAAN & GANGGUAN TULANG BELAKANG SEDANG
7.579.977
165
G-4-10-iii
KECEDERAAN & GANGGUAN TULANG BELAKANG BERAT
11.906.630
166
G-4-11-i
TUMOR SISTEM PERSARAFAN & GANGGUAN DEGENERATIF RINGAN
11.022.056
167
G-4-11-ii
TUMOR SISTEM PERSARAFAN & GANGGUAN DEGENERATIF SEDANG
12.785.585
Deskripsi (INA-CBG)
Tarif
INA-CBG
14.368.993
- 1050 No
Kode
INA-CBG
168
G-4-11-iii
TUMOR SISTEM PERSARAFAN & GANGGUAN DEGENERATIF BERAT
169
G-4-12-i
SKLEROSIS MULTIPLE & ATAXIA CEREBELAR RINGAN
8.243.528
170
G-4-12-ii
SKLEROSIS MULTIPLE & ATAXIA CEREBELAR SEDANG
10.386.845
171
G-4-12-iii
SKLEROSIS MULTIPLE & ATAXIA CEREBELAR BERAT
15.085.656
172
G-4-13-i
PERDARAHAN INTRA KRANIAL BUKAN TRAUMATIK RINGAN
4.586.644
173
G-4-13-ii
PERDARAHAN INTRA KRANIAL BUKAN TRAUMATIK SEDANG
7.579.977
174
G-4-13-iii
PERDARAHAN INTRA KRANIAL BUKAN TRAUMATIK BERAT
8.960.609
175
G-4-14-i
KECEDERAAN PEMBULUH DARAH OTAK DENGAN INFARK RINGAN
8.388.288
176
G-4-14-ii
KECEDERAAN PEMBULUH DARAH OTAK DENGAN INFARK SEDANG
13.801.564
177
G-4-14-iii
KECEDERAAN PEMBULUH DARAH OTAK DENGAN INFARK BERAT
17.279.873
178
G-4-15-i
179
G-4-15-ii
180
G-4-15-iii
181
G-4-16-i
5.414.270
182
G-4-16-ii
8.097.089
183
G-4-16-iii
184
G-4-17-i
GANGUAN PERSARAFAN KRANIAL DAN PERIFER RINGAN
7.955.662
185
G-4-17-ii
GANGUAN PERSARAFAN KRANIAL DAN PERIFER SEDANG
9.873.326
186
G-4-17-iii
GANGUAN PERSARAFAN KRANIAL DAN PERIFER BERAT
187
G-4-18-i
INFEKSI TUBERKULOSA DAN BAKTERI SISTEM PERSARAFAN RINGAN
6.497.123
188
G-4-18-ii
INFEKSI TUBERKULOSA DAN BAKTERI SISTEM PERSARAFAN SEDANG
9.578.429
189
G-4-18-iii
INFEKSI TUBERKULOSA DAN BAKTERI SISTEM PERSARAFAN BERAT
190
G-4-19-i
191
G-4-19-ii
192
G-4-19-iii
193
G-4-20-i
3.789.989
194
G-4-20-ii
5.381.788
195
G-4-20-iii
9.177.209
196
G-4-21-i
4.515.565
197
G-4-21-ii
6.276.635
198
G-4-21-iii
199
G-4-22-i
4.331.416
200
G-4-22-ii
5.414.270
201
G-4-22-iii
6.211.583
Deskripsi (INA-CBG)
KECEDERAAN PEMBULUH DARAH OTAK NON SPESIFIK & PENYUMBATAN PRECEREBRAL TANPA INFARK RINGAN
KECEDERAAN PEMBULUH DARAH OTAK NON SPESIFIK & PENYUMBATAN PRECEREBRAL TANPA INFARK SEDANG
KECEDERAAN PEMBULUH DARAH OTAK NON SPESIFIK & PENYUMBATAN PRECEREBRAL TANPA INFARK BERAT
INFEKSI NON BAKTERI SISTEM PERSARAFAN (TIDAK TERMASUK MENINGITIS VIRUS)

RINGAN
SEDANG
BERAT
Tarif
INA-CBG
18.737.496
6.497.123
8.236.890
12.468.450
14.694.770
16.547.776
10.147.370
5.563.964
10.972.745
16.367.853
11.017.978
- 1051 No
Kode
INA-CBG
202
G-4-23-i
4.331.416
203
G-4-23-ii
5.414.270
204
G-4-23-iii
7.739.315
205
G-4-24-i
4.331.416
206
G-4-24-ii
5.414.270
207
G-4-24-iii
TRAUMA KEPALA BERAT
208
G-4-25-i
GEGAR OTAK RINGAN
4.231.742
209
G-4-25-ii
GEGAR OTAK SEDANG
5.327.856
210
G-4-25-iii
GEGAR OTAK BERAT
6.760.744
211
G-4-26-i
GANGUAN-PENYAKIT SISTEM PERNAFASAN LAIN-LAIN (RINGAN)
6.711.504
212
G-4-26-ii
GANGUAN-PENYAKIT SISTEM PERNAFASAN LAIN-LAIN (SEDANG)
7.611.070
213
G-4-26-iii
GANGUAN-PENYAKIT SISTEM PERNAFASAN LAIN-LAIN (BERAT)
214
H-1-20-i
6.401.495
215
H-1-20-ii
11.673.850
216
H-1-20-iii
15.875.707
217
H-1-30-i
PROSEDUR LENSA DAN INTRA OKULER RINGAN
6.267.673
218
H-1-30-ii
PROSEDUR LENSA DAN INTRA OKULER SEDANG
7.145.147
219
H-1-30-iii
220
H-4-10-i
6.497.123
221
H-4-10-ii
10.828.539
222
H-4-10-iii
17.653.717
223
H-4-11-i
4.548.567
224
H-4-11-ii
5.020.744
225
H-4-11-iii
7.067.982
226
H-4-12-i
6.310.955
227
H-4-12-ii
8.548.601
228
H-4-12-iii
14.262.758
229
I-1-01-i
PROSEDUR TRANPLANTASI PARU ATAU/DAN JANTUNG RINGAN
93.445.103
230
I-1-01-ii
PROSEDUR TRANPLANTASI PARU ATAU/DAN JANTUNG SEDANG
95.501.382
231
I-1-01-iii
PROSEDUR TRANPLANTASI PARU ATAU/DAN JANTUNG BERAT
150.747.100
232
I-1-02-i
PROSEDUR KATUP JANTUNG DENGAN KATETERISASI RINGAN
51.842.805
233
I-1-02-ii
PROSEDUR KATUP JANTUNG DENGAN KATETERISASI SEDANG
66.877.218
234
I-1-02-iii
PROSEDUR KATUP JANTUNG DENGAN KATETERISASI BERAT
82.430.060
235
I-1-03-i
PROSEDUR OPERASI KARDIOTORASIK KOMPLEKS PADA JANTUNG ANOMALI RINGAN
31.926.643
Deskripsi (INA-CBG)
Tarif
INA-CBG
11.377.502
14.469.116
11.921.420
- 1052 No
Kode
INA-CBG
Deskripsi (INA-CBG)
236
I-1-03-ii
PROSEDUR OPERASI KARDIOTORASIK KOMPLEKS PADA JANTUNG ANOMALI SEDANG
43.760.961
237
I-1-03-iii
PROSEDUR OPERASI KARDIOTORASIK KOMPLEKS PADA JANTUNG ANOMALI BERAT
64.182.743
238
I-1-04-i
PROSEDUR KATUP JANTUNG TANPA KATETERISASI JANTUNG RINGAN
40.047.839
239
I-1-04-ii
PROSEDUR KATUP JANTUNG TANPA KATETERISASI JANTUNG SEDANG
51.442.160
240
I-1-04-iii
PROSEDUR KATUP JANTUNG TANPA KATETERISASI JANTUNG BERAT
241
I-1-05-i
242
I-1-05-ii
243
I-1-05-iii
244
I-1-06-i
33.255.819
245
I-1-06-ii
50.165.842
246
I-1-06-iii
91.074.934
247
I-1-07-i
PROSEDUR PEMBULUH DARAH TORASIK KOMPLEKS RINGAN
43.733.921
248
I-1-07-ii
PROSEDUR PEMBULUH DARAH TORASIK KOMPLEKS SEDANG
53.954.675
249
I-1-07-iii
PROSEDUR PEMBULUH DARAH TORASIK KOMPLEKS BERAT
58.864.200
250
I-1-11-i
251
I-1-11-ii
252
I-1-11-iii
253
I-1-12-i
24.797.878
254
I-1-12-ii
34.408.213
255
I-1-12-iii
47.991.335
256
I-1-13-i
PROSEDUR PEMBULUH DARAH ABDOMINAL KOMPLEK RINGAN
14.586.987
257
I-1-13-ii
PROSEDUR PEMBULUH DARAH ABDOMINAL KOMPLEK SEDANG
19.506.972
258
I-1-13-iii
PROSEDUR PEMBULUH DARAH ABDOMINAL KOMPLEK BERAT
31.809.458
259
I-1-14-i
PROSEDUR PEMASANGAN PACEMAKER JANTUNG PERMANEN RINGAN
53.367.593
260
I-1-14-ii
PROSEDUR PEMASANGAN PACEMAKER JANTUNG PERMANEN SEDANG
66.328.294
261
I-1-14-iii
PROSEDUR PEMASANGAN PACEMAKER JANTUNG PERMANEN BERAT
86.912.937
262
I-1-15-i
13.112.635
263
I-1-15-ii
30.632.673
264
I-1-15-iii
71.533.209
265
I-1-16-i
266
I-1-16-ii
267
I-1-16-iii
268
I-1-17-i
PROSEDUR PEMBEDAHAN BYPASS PEMBULUH KORONER DENGAN KATETERISASI

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
PROSEDUR DEFIBRILATOR JANTUNG DAN PEMASANGAN SISTEM BANTUAN JANTUNG

RINGAN
SEDANG
BERAT
PROSEDUR REVISI DEFIBRILATOR & PACEMAKER JANTUNG TIDAK TERMASUK

PROSEDUR LIGASI DAN STRIPPING PEMBULUH DARAH VENA RINGAN
Tarif
INA-CBG
109.664.005
68.615.477
82.338.572
113.297.356
8.319.258
9.250.183
12.309.174
22.871.826
59.466.747
68.593.433
7.542.010
- 1053 No
Kode
INA-CBG
269
I-1-17-ii
PROSEDUR LIGASI DAN STRIPPING PEMBULUH DARAH VENA SEDANG
15.622.237
270
I-1-17-iii
PROSEDUR LIGASI DAN STRIPPING PEMBULUH DARAH VENA BERAT
43.576.170
271
I-1-20-i
PROSEDUR SISTIM PEREDARAN DARAH LAIN-LAIN RINGAN
14.586.987
272
I-1-20-ii
PROSEDUR SISTIM PEREDARAN DARAH LAIN-LAIN SEDANG
24.558.541
273
I-1-20-iii
PROSEDUR SISTIM PEREDARAN DARAH LAIN BERAT
38.686.528
274
I-1-30-i
PROSEDUR PENGGANTIAN ALAT DEFIBRILATOR DAN PACEMAKER JANTUNG RINGAN
25.948.205
275
I-1-30-ii
PROSEDUR PENGGANTIAN ALAT DEFIBRILATOR DAN PACEMAKER JANTUNG SEDANG
53.977.508
276
I-1-30-iii
PROSEDUR PENGGANTIAN ALAT DEFIBRILATOR DAN PACEMAKER JANTUNG BERAT
83.645.534
277
I-1-40-i
PROSEDUR KARDIOVASKULAR PERKUTAN RINGAN
16.687.634
278
I-1-40-ii
PROSEDUR KARDIOVASKULAR PERKUTAN SEDANG
38.800.148
279
I-1-40-iii
PROSEDUR KARDIOVASKULAR PERKUTAN BERAT
57.006.192
280
I-4-10-i
10.434.485
281
I-4-10-ii
16.476.239
282
I-4-10-iii
23.768.412
283
I-4-11-i
12.372.571
284
I-4-11-ii
15.311.104
285
I-4-11-iii
26.353.914
286
I-4-12-i
10.837.086
287
I-4-12-ii
15.464.491
288
I-4-12-iii
18.760.603
289
I-4-13-i
THROMBOPHLEBITIS PADA PEMBULUH DARAH VENA RINGAN
290
I-4-13-ii
THROMBOPHLEBITIS DALAM PEMBULUH DARAH VENA SEDANG
14.142.507
291
I-4-13-iii
THROMBOPHLEBITIS DALAM PEMBULUH DARAH VENA BERAT
28.154.202
292
I-4-14-i
6.054.073
293
I-4-14-ii
7.084.161
294
I-4-14-iii
295
I-4-15-i
GANGUAN PEMBULUH DARAH PERIFER LAIN-LAIN (RINGAN)
8.662.831
296
I-4-15-ii
GANGUAN PEMBULUH DARAH PERIFER LAIN-LAIN (SEDANG)
12.750.953
297
I-4-15-iii
GANGUAN PEMBULUH DARAH PERIFER LAIN-LAIN (BERAT)
14.533.019
298
I-4-16-i
6.497.123
299
I-4-16-ii
10.529.600
300
I-4-16-iii
13.265.425
301
I-4-17-i
HIPERTENSI RINGAN
5.978.752
302
I-4-17-ii
HIPERTENSI SEDANG
8.234.323
Deskripsi (INA-CBG)
Tarif
INA-CBG
9.734.682
10.978.093
- 1054 No
Kode
INA-CBG
303
I-4-17-iii
HIPERTENSI BERAT
304
I-4-18-i
GANGUAN KATUP JANTUNG KONGENITAL RINGAN
8.804.984
305
I-4-18-ii
GANGUAN KATUP JANTUNG KONGENITAL SEDANG
13.488.646
306
I-4-18-iii
GANGUAN-PENYAKIT KATUP JANTUNG KONGENITAL BERAT
18.184.857
307
I-4-19-i
GANGGUAN KONDUKSI & ARITMIA JANTUNG RINGAN
6.891.054
308
I-4-19-ii
GANGGUAN KONDUKSI & ARITMIA JANTUNG SEDANG
11.186.628
309
I-4-19-iii
GANGGUAN KONDUKSI & ARITMIA JANTUNG BERAT
13.085.423
310
I-4-20-i
8.363.270
311
I-4-20-ii
9.635.112
312
I-4-20-iii
12.787.397
313
I-4-21-i
11.121.796
314
I-4-21-ii
13.873.719
315
I-4-21-iii
18.926.694
316
I-4-22-i
7.038.550
317
I-4-22-ii
8.110.517
318
I-4-22-iii
319
I-4-23-i
320
I-4-23-ii
321
I-4-23-iii
322
I-4-24-i
DIAGNOSIS SISTEM PEMBULUH DARAH LAIN-LAIN (RINGAN)
6.538.979
323
I-4-24-ii
DIAGNOSIS SISTEM PEMBULUH DARAH LAIN-LAIN (SEDANG)
16.326.021
324
I-4-24-iii
DIAGNOSIS SISTEM PEMBULUH DARAH LAIN-LAIN (BERAT)
20.641.304
325
J-1-01-i
PROSEDUR VENTILASI MEKANIKAL LONG TERM DENGAN TRAKEOSTOMI RINGAN
52.682.543
326
J-1-01-ii
PROSEDUR VENTILASI MEKANIKAL LONG TERM DENGAN TRAKEOSTOMI SEDANG
56.889.249
327
J-1-01-iii
PROSEDUR VENTILASI MEKANIKAL LONG TERM DENGAN TRAKEOSTOMI BERAT
96.155.684
328
J-1-02-i
PROSEDUR VENTILASI MEKANIKAL LONG TERM TANPA TRAKEOSTOMI RINGAN
26.930.271
329
J-1-02-ii
PROSEDUR VENTILASI MEKANIKAL LONG TERM TANPA TRAKEOSTOMI SEDANG
28.849.496
330
J-1-02-iii
PROSEDUR VENTILASI MEKANIKAL LONG TERM TANPA TRAKEOSTOMI BERAT
42.631.334
331
J-1-10-i
PROSEDUR SISTEM PERNAFASAN KOMPLEKS RINGAN
10.508.581
332
J-1-10-ii
PROSEDUR SISTEM PERNAFASAN KOMPLEKS SEDANG
25.382.042
333
J-1-10-iii
PROSEDUR SISTEM PERNAFASAN KOMPLEKS BERAT
44.942.025
334
J-1-20-i
PROSEDUR SISTEM PERNAFASAN NON KOMPLEKS RINGAN
9.082.777
335
J-1-20-ii
PROSEDUR SISTEM PERNAFASAN NON KOMPLEKS SEDANG
13.210.181
336
J-1-20-iii
PROSEDUR SISTEM PERNAFASAN NON KOMPLEKS BERAT
19.864.033
Deskripsi (INA-CBG)
KOMPLIKASI, REAKSI, MALFUNGSI DARI PROSEDUR ATAU PEMASANGAN ALAT

Tarif
INA-CBG
10.017.447
11.833.024
5.332.099
6.546.589
12.791.438
- 1055 No
Kode
INA-CBG
337
J-1-30-i
PROSEDUR SISTEM PERNAFASAN MODERAT KOMPLEKS RINGAN
6.125.018
338
J-1-30-ii
PROSEDUR SISTEM PERNAFASAN MODERAT KOMPLEKS SEDANG
29.173.974
339
J-1-30-iii
PROSEDUR SISTEM PERNAFASAN MODERAT KOMPLEKS BERAT
87.987.424
340
J-4-10-i
6.875.226
341
J-4-10-ii
9.830.747
342
J-4-10-iii
343
J-4-11-i
4.459.695
344
J-4-11-ii
6.207.794
345
J-4-11-iii
8.895.927
346
J-4-12-i
EMBOLI PARU RINGAN
6.633.000
347
J-4-12-ii
EMBOLI PARU SEDANG
8.589.508
348
J-4-12-iii
EMBOLI PARU BERAT
11.470.420
349
J-4-13-i
10.505.440
350
J-4-13-ii
15.442.996
351
J-4-13-iii
25.108.001
352
J-4-14-i
TUMOR PARU RINGAN
7.159.125
353
J-4-14-ii
TUMOR PARU SEDANG
11.992.515
354
J-4-14-iii
TUMOR PARU BERAT
14.258.490
355
J-4-15-i
PERADANGAN DAN INFEKSI PERNAFASAN RINGAN
6.497.123
356
J-4-15-ii
PERADANGAN DAN INFEKSI PERNAFASAN SEDANG
8.825.071
357
J-4-15-iii
PERADANGAN DAN INFEKSI PERNAFASAN BERAT
358
J-4-16-i
SIMPLE PNEUMONIA & WHOOPING COUGH RINGAN
5.414.270
359
J-4-16-ii
SIMPLE PNEUMONIA & WHOOPING COUGH SEDANG
7.579.977
360
J-4-16-iii
SIMPLE PNEUMONIA & WHOOPING COUGH BERAT
361
J-4-17-i
5.414.270
362
J-4-17-ii
6.964.524
363
J-4-17-iii
364
J-4-18-i
4.331.416
365
J-4-18-ii
5.955.696
366
J-4-18-iii
6.270.984
367
J-4-19-i
7.579.977
368
J-4-19-ii
8.825.006
369
J-4-19-iii
370
J-4-20-i
Deskripsi (INA-CBG)
Tarif
INA-CBG
14.872.453
11.089.832
13.673.482
11.944.588
13.571.341
7.579.977
- 1056 No
Kode
INA-CBG
371
J-4-20-ii
372
J-4-20-iii
373
J-4-21-i
GEJALA, TANDA DAN DIAGNOSIS SISTEM PERNAFASAN LAIN-LAIN (RINGAN)
4.331.416
374
J-4-21-ii
GEJALA, TANDA DAN DIAGNOSIS SISTEM PERNAFASAN LAIN-LAIN (SEDANG)
10.686.393
375
J-4-21-iii
GEJALA, TANDA DAN DIAGNOSIS SISTEM PERNAFASAN LAIN-LAIN (BERAT)
15.242.292
376
K-1-10-i
PROSEDUR NON KOMPLEKS USUS HALUS & USUS BESAR (RINGAN)
11.669.590
377
K-1-10-ii
PROSEDUR NON KOMPLEKS USUS HALUS & USUS BESAR (SEDANG)
16.744.890
378
K-1-10-iii
PROSEDUR NON KOMPLEKS USUS HALUS & USUS BESAR (BERAT)
19.611.149
379
K-1-11-i
10.316.985
380
K-1-11-ii
13.544.956
381
K-1-11-iii
34.374.431
382
K-1-12-i
PROSEDUR HERNIA TIDAK TERMASUK INGUINAL & FEMORAL (RINGAN)
5.549.748
383
K-1-12-ii
PROSEDUR HERNIA TIDAK TERMASUK INGUINAL & FEMORAL (SEDANG)
7.233.038
384
K-1-12-iii
PROSEDUR HERNIA TIDAK TERMASUK INGUINAL & FEMORAL (BERAT)
385
K-1-13-i
6.303.753
386
K-1-13-ii
11.010.846
387
K-1-13-iii
11.775.703
388
K-1-14-i
PROSEDUR HERNIA INGUINAL DAN FEMORAL RINGAN
10.187.238
389
K-1-14-ii
PROSEDUR HERNIA INGUINAL DAN FEMORAL SEDANG
11.966.065
390
K-1-14-iii
PROSEDUR HERNIA INGUINAL DAN FEMORAL BERAT
29.463.922
391
K-1-20-i
19.766.230
392
K-1-20-ii
27.588.445
393
K-1-20-iii
58.930.221
394
K-1-30-i
PROSEDUR DUODENUM, ESOFAGUS & LAMBUNG NON KOMPLEKS (RINGAN)
13.011.116
395
K-1-30-ii
PROSEDUR DUODENUM, ESOFAGUS & LAMBUNG NON KOMPLEKS (SEDANG)
23.339.179
396
K-1-30-iii
PROSEDUR DUODENUM, ESOFAGUS & LAMBUNG NON KOMPLEKS (BERAT)
37.372.683
397
K-1-40-i
PROSEDUR SISTEM PENCERNAAN LAIN-LAIN (RINGAN)
13.071.237
398
K-1-40-ii
PROSEDUR SISTEM PENCERNAAN LAIN-LAIN (SEDANG)
14.383.598
399
K-1-40-iii
PROSEDUR SISTEM PENCERNAAN LAIN-LAIN (BERAT)
23.853.813
400
K-1-50-i
9.970.200
401
K-1-50-ii
12.911.880
402
K-1-50-iii
PROSEDUR ANAL BERAT
18.331.435
403
K-4-10-i
7.551.709
404
K-4-10-ii
9.036.064
Deskripsi (INA-CBG)
Tarif
INA-CBG
9.506.888
20.893.014
14.388.034
- 1057 No
Kode
INA-CBG
405
K-4-10-iii
406
K-4-11-i
4.331.416
407
K-4-11-ii
6.497.123
408
K-4-11-iii
409
K-4-12-i
4.331.416
410
K-4-12-ii
6.653.534
411
K-4-12-iii
412
K-4-13-i
413
K-4-13-ii
414
K-4-13-iii
DIVERTIKULITIS, DIVERTIKULOSIS DAN PENYAKIT PERADANGAN USUS BESAR (BERAT)
415
K-4-14-i
INSUFISIENSI PEMBULUH DARAH GASTROINTESTINAL RINGAN
5.414.270
416
K-4-14-ii
INSUFISIENSI PEMBULUH DARAH GASTROINTESTINAL SEDANG
7.327.649
417
K-4-14-iii
INSUFISIENSI PEMBULUH DARAH GASTROINTESTINAL BERAT
418
K-4-15-i
OBSTRUKSI SALURAN GASTROINTESTINAL RINGAN
5.414.270
419
K-4-15-ii
OBSTRUKSI SALURAN GASTROINTESTINAL SEDANG
10.180.303
420
K-4-15-iii
OBSTRUKSI SALURAN GASTROINTESTINAL BERAT
14.484.739
421
K-4-16-i
5.414.270
422
K-4-16-ii
6.497.123
423
K-4-16-iii
8.154.204
424
K-4-17-i
NYERI ABDOMEN & GASTROENTERITIS LAIN-LAIN (RINGAN)
4.331.416
425
K-4-17-ii
NYERI ABDOMEN & GASTROENTERITIS LAIN-LAIN (SEDANG)
6.497.812
426
K-4-17-iii
NYERI ABDOMEN & GASTROENTERITIS LAIN-LAIN (BERAT)
8.647.924
427
K-4-18-i
DIAGNOSIS SISTEM PENCERNAAN LAIN-LAIN (RINGAN)
4.439.044
428
K-4-18-ii
DIAGNOSIS SISTEM PENCERNAAN LAIN-LAIN (SEDANG)
6.913.756
429
K-4-18-iii
DIAGNOSIS SISTEM PENCERNAAN LAIN-LAIN (BERAT)
8.039.100
430
L-1-20-i
PROSEDUR PEMINDAHAN KULIT PADA LUKA BAKAR RINGAN
25.908.300
431
L-1-20-ii
PROSEDUR PEMINDAHAN KULIT PADA LUKA BAKAR SEDANG
27.066.602
432
L-1-20-iii
PROSEDUR PEMINDAHAN KULIT PADA LUKA BAKAR BERAT
72.637.327
433
L-1-30-i
PROSEDUR PEMINDAHAN KULIT TANPA LUKA BAKAR RINGAN
20.421.782
434
L-1-30-ii
PROSEDUR PEMINDAHAN KULIT TANPA LUKA BAKAR SEDANG
29.942.237
435
L-1-30-iii
PROSEDUR PEMINDAHAN KULIT TANPA LUKA BAKAR BERAT
31.579.718
436
L-1-40-i
PROSEDUR PADA KULIT, JARINGAN BAWAH KULIT DAN PAYUDARA RINGAN
8.346.412
437
L-1-40-ii
PROSEDUR PADA KULIT, JARINGAN BAWAH KULIT DAN PAYUDARA SEDANG
18.785.268
438
L-1-40-iii
PROSEDUR PADA KULIT, JARINGAN BAWAH KULIT DAN PAYUDARA BERAT
31.836.065
Deskripsi (INA-CBG)
DIVERTIKULITIS, DIVERTIKULOSIS DAN PENYAKIT PERADANGAN USUS BESAR

(RINGAN)
(SEDANG)
Tarif
INA-CBG
36.392.069
11.807.614
15.968.007
6.497.123
8.415.374
13.763.870
11.083.768
- 1058 No
Kode
INA-CBG
439
L-1-50-i
14.586.987
440
L-1-50-ii
26.256.577
441
L-1-50-iii
31.747.916
442
L-4-10-i
6.497.123
443
L-4-10-ii
7.660.434
444
L-4-10-iii
445
L-4-11-i
6.318.370
446
L-4-11-ii
8.656.056
447
L-4-11-iii
448
L-4-12-i
6.497.123
449
L-4-12-ii
9.801.586
450
L-4-12-iii
451
L-4-13-i
TRAUMA PADA KULIT, JARINGAN BAWAH KULIT DAN PAYUDARA RINGAN
4.193.038
452
L-4-13-ii
TRAUMA PADA KULIT, JARINGAN BAWAH KULIT DAN PAYUDARA SEDANG
4.834.820
453
L-4-13-iii
TRAUMA PADA KULIT, JARINGAN BAWAH KULIT DAN PAYUDARA BERAT
7.252.607
454
L-4-14-i
GANGGUAN PADA KULIT & PAYUDARA LAIN-LAIN (RINGAN)
4.331.416
455
L-4-14-ii
GANGGUAN PADA KULIT & PAYUDARA LAIN-LAIN (SEDANG)
6.497.123
456
L-4-14-iii
GANGGUAN PADA KULIT & PAYUDARA LAIN-LAIN (BERAT)
457
M-1-01-i
458
M-1-01-ii
459
M-1-01-iii
460
M-1-02-i
15.378.192
461
M-1-02-ii
25.248.068
462
M-1-02-iii
45.723.094
463
M-1-03-i
464
M-1-03-ii
465
M-1-03-iii
466
M-1-04-i
467
M-1-04-ii
468
M-1-04-iii
469
M-1-05-i
470
M-1-05-ii
471
M-1-05-iii
Deskripsi (INA-CBG)
PROSEDUR BILATERAL DAN MULTIPLE SENDI ANGGOTA TUBUH BAWAH MAYOR

(RINGAN)
(SEDANG)
(BERAT)
PROSEDUR FUSI TULANG BELAKANG PADA LENGKUNGAN TULANG BELAKANG

RINGAN
SEDANG
BERAT
PROSEDUR PADA SENDI TUNGKAI/ANGGOTA TUBUH BAGIAN BAWAH MAYOR
(RINGAN)
(SEDANG)
(BERAT)
PROSEDUR PADA SENDI LENGAN/ANGGOTA TUBUH BAGIAN BAWAH MAYOR
(RINGAN)
(SEDANG)
(BERAT)
Tarif
INA-CBG
15.766.012
23.474.143
15.985.357
10.444.807
21.117.339
23.570.366
33.109.979
37.926.166
44.384.706
45.219.660
10.144.532
13.005.185
16.273.538
15.803.234
18.264.303
31.109.083
- 1059 No
Kode
INA-CBG
472
M-1-07-i
473
M-1-07-ii
474
M-1-07-iii
475
M-1-10-i
PROSEDUR KRANIAL DAN REKONSTRUKSI TULANG WAJAH RINGAN
10.902.513
476
M-1-10-ii
PROSEDUR KRANIAL DAN REKONSTRUKSI TULANG WAJAH SEDANG
23.060.925
477
M-1-10-iii
PROSEDUR KRANIAL DAN REKONSTRUKSI TULANG WAJAH BERAT
54.137.364
478
M-1-20-i
PROSEDUR PAHA DAN SENDI PANGGUL SELAIN SENDI MAYOR RINGAN
10.785.402
479
M-1-20-ii
PROSEDUR PAHA DAN SENDI PANGGUL SELAIN SENDI MAYOR SEDANG
12.218.408
480
M-1-20-iii
PROSEDUR PAHA DAN SENDI PANGGUL SELAIN SENDI MAYOR BERAT
29.924.901
481
M-1-30-i
6.451.283
482
M-1-30-ii
13.329.992
483
M-1-30-iii
PROSEDUR KAKI BERAT
19.885.537
484
M-1-40-i
PROSEDUR EKSISI LOKAL DAN PENGANGKATAN ALAT FIKSASI INTERNAL RINGAN
6.370.645
485
M-1-40-ii
PROSEDUR EKSISI LOKAL DAN PENGANGKATAN ALAT FIKSASI INTERNAL SEDANG
11.669.590
486
M-1-40-iii
PROSEDUR EKSISI LOKAL DAN PENGANGKATAN ALAT FIKSASI INTERNAL BERAT
20.421.782
487
M-1-50-i
8.632.959
488
M-1-50-ii
17.378.349
489
M-1-50-iii
23.339.179
Deskripsi (INA-CBG)
PROSEDUR FUSI TULANG BELAKANG SELAIN LENGKUNGAN TULANG BELAKANG
RINGAN
SEDANG
BERAT
PROSEDUR SISTEM MUSKULOSKLETAL & JARINGAN PENGHUBUNG LAIN-LAIN

(RINGAN)
(SEDANG)
(BERAT)
Tarif
INA-CBG
16.966.159
22.729.352
46.301.845
490
M-1-60-i
6.515.160
491
M-1-60-ii
492
M-1-60-iii
493
M-1-70-i
PROSEDUR LUTUT DAN TUNGKAI BAWAH SELAIN KAKI (RINGAN)
8.727.694
494
M-1-70-ii
PROSEDUR LUTUT DAN TUNGKAI BAWAH SELAIN KAKI (SEDANG)
17.808.819
495
M-1-70-iii
PROSEDUR LUTUT DAN TUNGKAI BAWAH SELAIN KAKI (BERAT)
28.709.967
496
M-1-80-i
7.032.160
497
M-1-80-ii
10.631.187
498
M-1-80-iii
24.475.747
499
M-4-10-i
4.331.416
500
M-4-10-ii
6.794.998
501
M-4-10-iii
FRAKTUR FEMUR BERAT
502
M-4-11-i
FRAKTUR PELVIS ATAU DISLOKASI SENDI PANGGUL RINGAN
5.894.046
503
M-4-11-ii
FRAKTUR PELVIS ATAU DISLOKASI SENDI PANGGUL SEDANG
13.521.820
504
M-4-11-iii
FRAKTUR PELVIS ATAU DISLOKASI SENDI PANGGUL BERAT
24.000.914
505
M-4-12-i
FRAKTUR/DISLOKASI SELAIN FEMUR DAN PELVIS RINGAN
4.331.416
13.043.392
22.700.116
14.428.819
- 1060 No
Kode
INA-CBG
506
M-4-12-ii
FRAKTUR/DISLOKASI SELAIN FEMUR DAN PELVIS SEDANG
507
M-4-12-iii
FRAKTUR/DISLOKASI SELAIN FEMUR DAN PELVIS BERAT
508
M-4-13-i
TUMOR MUSKULOSKLETAL,JARINGAN KONEKTIF DAN FRAKTUR PATOLOGIS RINGAN
8.221.646
509
M-4-13-ii
TUMOR MUSKULOSKLETAL,JARINGAN KONEKTIF DAN FRAKTUR PATOLOGIS SEDANG
10.828.539
510
M-4-13-iii
TUMOR MUSKULOSKLETAL,JARINGAN KONEKTIF DAN FRAKTUR PATOLOGIS BERAT
24.457.336
511
M-4-14-i
8.662.831
512
M-4-14-ii
11.563.803
513
M-4-14-iii
OSTEOMIELITIS BERAT
17.321.330
514
M-4-15-i
5.557.077
515
M-4-15-ii
7.409.904
516
M-4-15-iii
517
M-4-16-i
5.551.708
518
M-4-16-ii
8.662.831
519
M-4-16-iii
520
M-4-17-i
MASALAH BAGIAN PUNGGUNG/PINGGANG BELAKANG RINGAN
5.414.270
521
M-4-17-ii
MASALAH BAGIAN PUNGGUNG/PINGGANG BELAKANG SEDANG
7.579.977
522
M-4-17-iii
MASALAH BAGIAN PUNGGUNG/PINGGANG BELAKANG BERAT
523
M-4-18-i
PENYAKIT TULANG DAN SENDI LAIN-LAIN RINGAN
6.525.315
524
M-4-18-ii
PENYAKIT TULANG DAN SENDI LAIN-LAIN SEDANG
8.662.831
525
M-4-18-iii
Deskripsi (INA-CBG)
PENYAKIT TULANG DAN SENDI LAIN-LAIN BERAT

MALFUNGSI, REAKSI ATAU KOMPLIKASI DARI PROSEDUR ATAU PEMASANGAN ALAT
ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
TANDA-TANDA, GEJALA, MUSKULOSKLETAL , KESELEO DAN PERADANGAN MINOR
(RINGAN)
(SEDANG)
(BERAT)
DIAGNOSIS SISTEM MUSKULOSKLETAL & JARINGAN PENGHUBUNG LAIN-LAIN
(RINGAN)
(SEDANG)
(BERAT)
Tarif
INA-CBG
7.881.006
16.228.645
18.408.516
16.562.114
10.585.841
11.066.553
526
M-4-19-i
4.851.660
527
M-4-19-ii
528
M-4-19-iii
529
M-4-20-i
530
M-4-20-ii
531
M-4-20-iii
532
M-4-21-i
533
M-4-21-ii
534
M-4-21-iii
535
N-1-01-i
11.719.639
536
N-1-01-ii
15.850.547
537
N-1-01-iii
33.607.875
538
N-1-11-i
PROSEDUR KANDUNG KEMIH KOMPLEK RINGAN
16.624.044
8.171.749
15.960.030
4.331.416
6.497.123
7.200.344
4.331.416
5.813.002
14.169.646
- 1061 No
Kode
INA-CBG
539
N-1-11-ii
PROSEDUR KANDUNG KEMIH KOMPLEK SEDANG
22.483.643
540
N-1-11-iii
46.678.358
541
N-1-12-i
PROSEDUR MEMBUAT BARU, MEREVISI DAN MEMINDAHKAN ALAT DIALISIS RINGAN
8.752.192
542
N-1-12-ii
PROSEDUR MEMBUAT BARU, MEREVISI DAN MEMINDAHKAN ALAT DIALISIS SEDANG
20.935.489
543
N-1-12-iii
PROSEDUR MEMBUAT BARU, MEREVISI DAN MEMINDAHKAN ALAT DIALISIS BERAT
38.156.233
544
N-1-20-i
12.183.908
545
N-1-20-ii
24.156.357
546
N-1-20-iii
27.632.683
547
N-1-30-i
PROSEDUR KANDUNG KEMIH DAN SALURAN URIN BAWAH RINGAN
14.494.909
548
N-1-30-ii
PROSEDUR KANDUNG KEMIH DAN SALURAN URIN BAWAH SEDANG
22.026.821
549
N-1-30-iii
PROSEDUR KANDUNG KEMIH DAN SALURAN URIN BAWAH BERAT
25.356.504
550
N-1-40-i
PROSEDUR PADA URETRA DAN TRANSURETRA RINGAN
13.061.331
551
N-1-40-ii
PROSEDUR PADA URETRA DAN TRANSURETRA SEDANG
17.705.101
552
N-1-40-iii
PROSEDUR PADA URETRA DAN TRANSURETRA BERAT
20.591.544
553
N-4-10-i
TUMOR GINJAL & SALURAN URIN & GAGAL GINJAL RINGAN
5.414.270
554
N-4-10-ii
TUMOR GINJAL & SALURAN URIN & GAGAL GINJAL SEDANG
7.454.284
555
N-4-10-iii
TUMOR GINJAL & SALURAN URIN & GAGAL GINJAL BERAT
556
N-4-11-i
4.263.178
557
N-4-11-ii
7.204.668
558
N-4-11-iii
8.244.492
559
N-4-12-i
4.331.416
560
N-4-12-ii
6.497.123
561
N-4-12-iii
562
N-4-13-i
BATU URIN RINGAN
5.875.601
563
N-4-13-ii
BATU URIN SEDANG
7.083.765
564
N-4-13-iii
BATU URIN BERAT
565
N-4-14-i
566
N-4-14-ii
567
N-4-14-iii
568
N-4-15-i
GEJALA, TANDA-TANDA PADA GINJAL DAN SALURAN URIN RINGAN
5.723.049
569
N-4-15-ii
GEJALA, TANDA-TANDA PADA GINJAL DAN SALURAN URIN SEDANG
7.853.804
570
N-4-15-iii
GEJALA, TANDA-TANDA PADA GINJAL DAN SALURAN URIN BERAT
8.962.608
571
N-4-16-i
DIAGNOSIS GINJAL DAN SALURAN URIN LAIN-LAIN (RINGAN)
5.747.763
572
N-4-16-ii
DIAGNOSIS GINJAL DAN SALURAN URIN LAIN-LAIN (SEDANG)
8.662.831
Deskripsi (INA-CBG)
MALFUNGSI, REAKSI ATAU KOMPLIKASI DARI PEMASANGAN ALAT SALURAN URIN,

PEMINDAHAN KULIT ATAU PENCAKOKAN (RINGAN)
PEMINDAHAN KULIT ATAU PENCAKOKAN (SEDANG)
PEMINDAHAN KULIT ATAU PENCAKOKAN (BERAT)
Tarif
INA-CBG
15.868.635
10.787.361
17.445.370
3.751.809
5.777.313
9.368.961
- 1062 No
Kode
INA-CBG
573
N-4-16-iii
574
O-6-10-i
PROSEDUR OPERASI PEMBEDAHAN CAESAR RINGAN
5.346.496
575
O-6-10-ii
PROSEDUR OPERASI PEMBEDAHAN CAESAR SEDANG
7.936.650
576
O-6-10-iii
PROSEDUR OPERASI PEMBEDAHAN CAESAR BERAT
9.780.641
Deskripsi (INA-CBG)
DIAGNOSIS GINJAL DAN SALURAN URIN LAIN-LAIN (BERAT)
PROSEDUR PERSALINAN VAGINAL DENGAN STERILISASI &/ DILATASI & KURET

RINGAN
SEDANG
Tarif
INA-CBG
18.216.645
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
2.352.346
584
O-6-13-ii
4.132.114
585
O-6-13-iii
5.138.831
586
P-8-01-i
587
P-8-01-ii
588
P-8-01-iii
589
P-8-02-i
590
P-8-02-ii
591
P-8-02-iii
592
P-8-03-i
593
P-8-03-ii
594
P-8-03-iii
595
P-8-04-i
596
P-8-04-ii
597
P-8-04-iii
598
P-8-05-i
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii
603
P-8-06-iii
604
P-8-07-i
PROSEDUR PERSALINAN VAGINAL DENGAN STERILISASI &/ DILATASI & KURET BERAT
PROSEDUR PERSALINAN VAGINAL DENGAN PROSEDUR SELAIN STERILISASI &/
DILATASI &KURET RINGAN
DILATASI & KURET SEDANG
DILATASI & KURET BERAT
PROSEDUR NEONATAL DENGAN PENCANGKOKAN ORGAN ATAU OKSIGENASI

PROSEDUR NEONATAL, BERAT BADAN LAHIR GROUP-1 DENGAN PROSEDUR MAYOR
RINGAN
SEDANG
BERAT
PROSEDUR NEONATAL, BERAT BADAN LAHIR GROUP-1 TANPA PROSEDUR MAYOR
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
RINGAN
4.513.355
7.353.579
12.462.035
4.991.416
5.994.678
7.531.454
108.830.450
134.660.658
158.053.863
135.574.572
155.517.989
177.690.422
7.293.493
10.210.891
16.084.469
66.972.674
86.916.091
124.615.797
36.417.569
51.616.994
76.050.711
5.834.795
15.095.860
28.080.022
10.210.891
- 1063 No
Kode
INA-CBG
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
NEONATAL, BBL GROUP-2 TANPA PROSEDUR MAYOR RINGAN
7.565.310
614
P-8-11-ii
NEONATAL, BBL GROUP-2 TANPA PROSEDUR MAYOR SEDANG
28.302.621
615
P-8-11-iii
NEONATAL, BBL GROUP-2 TANPA PROSEDUR MAYOR BERAT
28.895.565
616
P-8-12-i
12.641.007
617
P-8-12-ii
16.507.390
618
P-8-12-iii
18.455.402
619
P-8-13-i
3.241.591
620
P-8-13-ii
5.998.538
621
P-8-13-iii
8.971.455
622
P-8-14-i
623
P-8-14-ii
624
P-8-14-iii
625
P-8-15-i
NEONATAL, BBL GROUP-5 DENGAN SINDROMA ASPIRASI RINGAN
4.454.073
626
P-8-15-ii
NEONATAL, BBL GROUP-5 DENGAN SINDROMA ASPIRASI SEDANG
8.902.520
627
P-8-15-iii
NEONATAL, BBL GROUP-5 DENGAN SINDROMA ASPIRASI BERAT
628
P-8-16-i
NEONATAL, BBL GROUP-5 DENGAN KONGENITAL/INFEKSI PERINATAL RINGAN
4.031.988
629
P-8-16-ii
NEONATAL, BBL GROUP-5 DENGAN KONGENITAL/INFEKSI PERINATAL SEDANG
5.719.547
630
P-8-16-iii
NEONATAL, BBL GROUP-5 DENGAN KONGENITAL/INFEKSI PERINATAL BERAT
7.424.254
631
P-8-17-i
2.656.272
632
P-8-17-ii
8.839.286
633
P-8-17-iii
634
S-4-10-i
KECEDERAAN PADA TEMPAT YANG TAK SPESIFIK ATAU BANYAK TEMPAT (RINGAN)
4.331.416
635
S-4-10-ii
KECEDERAAN PADA TEMPAT YANG TAK SPESIFIK ATAU BANYAK TEMPAT (SEDANG)
5.414.270
636
S-4-10-iii
KECEDERAAN PADA TEMPAT YANG TAK SPESIFIK ATAU BANYAK TEMPAT (BERAT)
7.037.621
637
S-4-11-i
2.707.135
Deskripsi (INA-CBG)
SEDANG
BERAT
PROSEDUR NEONATAL, BERAT BADAN LAHIR GROUP-5 DENGAN SINDROMA DISTRES
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
NEONATAL, MENINGGAL DAN DITRANSFER KE FASILITAS PERAWATAN PASIEN AKUT
LAIN RINGAN
LAIN SEDANG
LAIN BERAT
NEONATAL, BBL GROUP-5 DENGAN ANOMALI MAYOR ATAU KONDISI HEREDITER

RINGAN
SEDANG
BERAT
Tarif
INA-CBG
28.628.880
37.926.166
7.608.296
10.801.047
15.247.761
4.720.178
6.837.865
13.424.744
5.922.723
12.092.524
13.265.454
10.457.388
17.841.535
- 1064 No
Kode
INA-CBG
638
S-4-11-ii
4.236.491
639
S-4-11-iii
6.665.941
640
S-4-12-i
3.248.562
641
S-4-12-ii
4.331.416
642
S-4-12-iii
8.459.598
643
S-4-13-i
KOMPLIKASI DARI PENATALAKSANAAN PASIEN RINGAN
4.331.416
644
S-4-13-ii
KOMPLIKASI DARI PENATALAKSANAAN PASIEN SEDANG
7.656.971
645
S-4-13-iii
KOMPLIKASI DARI PENATALAKSANAAN PASIEN BERAT
646
S-4-14-i
SINDROMA MALTREATMENT PADA DEWASA ATAU KANAK-KANAK RINGAN
2.639.052
647
S-4-14-ii
SINDROMA MALTREATMENT PADA DEWASA ATAU KANAK-KANAK SEDANG
5.606.231
648
S-4-14-iii
SINDROMA MALTREATMENT PADA DEWASA ATAU KANAK-KANAK BERAT
649
S-4-15-i
LUKA BAKAR, DIRUJUK KE FASILITAS PERAWATAN AKUT YANG LAIN (RINGAN)
1.995.939
650
S-4-15-ii
LUKA BAKAR, DIRUJUK KE FASILITAS PERAWATAN AKUT YANG LAIN (SEDANG)
3.767.017
651
S-4-15-iii
LUKA BAKAR, DIRUJUK KE FASILITAS PERAWATAN AKUT YANG LAIN (BERAT)
4.879.163
652
S-4-16-i
LUKA BAKAR RINGAN
7.579.977
653
S-4-16-ii
LUKA BAKAR SEDANG
11.007.260
654
S-4-16-iii
LUKA BAKAR BERAT
19.655.171
655
S-4-17-i
DIAGNOSIS KECEDERAAN, KERACUNAN DAN EFEK TOKSIK LAIN-LAIN RINGAN
4.155.760
656
S-4-17-ii
DIAGNOSIS KECEDERAAN, KERACUNAN DAN EFEK TOKSIK LAIN-LAIN SEDANG
5.414.270
657
S-4-17-iii
DIAGNOSIS KECEDERAAN, KERACUNAN DAN EFEK TOKSIK LAIN-LAIN BERAT
8.829.035
658
T-1-10-i
TERAPI REHABILITASI &/ DETOKSIKASI ALKOHOL & OBAT RINGAN
4.289.891
659
T-1-10-ii
TERAPI REHABILITASI &/ DETOKSIKASI ALKOHOL & OBAT SEDANG
5.761.033
660
T-1-10-iii
TERAPI REHABILITASI &/ DETOKSIKASI ALKOHOL & OBAT BERAT
661
T-4-10-i
662
T-4-10-ii
663
T-4-10-iii
664
T-4-11-i
PENYALAHGUNAAN & KETERGANTUNGAN ALKOHOL,OPIUM DAN KOKAIN RINGAN
1.855.772
665
T-4-11-ii
PENYALAHGUNAAN & KETERGANTUNGAN ALKOHOL,OPIUM DAN KOKAIN SEDANG
2.920.456
666
T-4-11-iii
PENYALAHGUNAAN & KETERGANTUNGAN ALKOHOL,OPIUM DAN KOKAIN BERAT
4.703.995
667
T-4-12-i
PENYALAHGUNAAN & KETERGANTUNGAN OBAT LAIN-LAIN (RINGAN)
3.789.989
668
T-4-12-ii
PENYALAHGUNAAN & KETERGANTUNGAN OBAT LAIN-LAIN (SEDANG)
5.728.359
669
T-4-12-iii
PENYALAHGUNAAN & KETERGANTUNGAN OBAT LAIN-LAIN (BERAT)
8.911.269
670
U-1-10-i
4.034.096
671
U-1-10-ii
8.231.820
Deskripsi (INA-CBG)
PENYALAHGUNAAN & KETERGANTUNGAN OBAT DAN ALKOHOL, MENOLAK

NASEHAT DOKTER RINGAN
NASEHAT DOKTER SEDANG
NASEHAT DOKTER BERAT
Tarif
INA-CBG
15.590.568
10.631.412
10.481.196
1.825.059
3.478.158
5.056.298
- 1065 No
Kode
INA-CBG
672
U-1-10-iii
35.546.663
673
U-1-11-i
PROSEDUR KOMPLEK LEHER DAN KEPALA LAIN-LAIN (RINGAN)
17.504.384
674
U-1-11-ii
PROSEDUR KOMPLEK LEHER DAN KEPALA LAIN-LAIN (SEDANG)
23.339.179
675
U-1-11-iii
PROSEDUR KOMPLEK LEHER DAN KEPALA LAIN-LAIN (BERAT)
40.317.565
676
U-1-12-i
10.998.747
677
U-1-12-ii
26.256.577
678
U-1-12-iii
34.094.662
679
U-1-13-i
11.669.590
680
U-1-13-ii
13.537.721
681
U-1-13-iii
25.388.654
682
U-1-14-i
PROSEDUR OPERASI BIBIR SUMBING & LANGIT-LANGIT MULUT (RINGAN)
6.620.472
683
U-1-14-ii
PROSEDUR OPERASI BIBIR SUMBING & LANGIT-LANGIT MULUT (SEDANG)
8.124.650
684
U-1-14-iii
PROSEDUR OPERASI BIBIR SUMBING & LANGIT-LANGIT MULUT (BERAT)
9.627.939
685
U-1-15-i
3.888.456
686
U-1-15-ii
5.525.224
687
U-1-15-iii
10.887.676
688
U-1-20-i
PROSEDUR TENGGOROKAN, MULUT, HIDUNG DAN TELINGA LAIN-LAIN (RINGAN)
10.057.741
689
U-1-20-ii
PROSEDUR TENGGOROKAN, MULUT, HIDUNG DAN TELINGA LAIN-LAIN (SEDANG)
17.902.779
690
U-1-20-iii
PROSEDUR TENGGOROKAN, MULUT, HIDUNG DAN TELINGA LAIN-LAIN (BERAT)
42.955.582
691
U-1-30-i
8.627.788
692
U-1-30-ii
11.647.514
693
U-1-30-iii
22.832.476
694
U-4-10-i
TUMOR KERONGKONGAN, MULUT, HIDUNG DAN TELINGA RINGAN
8.031.029
695
U-4-10-ii
TUMOR KERONGKONGAN, MULUT, HIDUNG DAN TELINGA SEDANG
20.132.104
696
U-4-10-iii
TUMOR KERONGKONGAN, MULUT, HIDUNG DAN TELINGA BERAT
29.368.356
697
U-4-11-i
4.331.416
698
U-4-11-ii
6.497.123
699
U-4-11-iii
9.238.862
700
U-4-12-i
4.331.416
701
U-4-12-ii
5.191.813
702
U-4-12-iii
8.254.747
703
U-4-13-i
PERADANGAN EPIGLOTIS, TELINGA TENGAH, ISPA DAN LARINGOTRAKEITIS RINGAN
4.331.416
704
U-4-13-ii
PERADANGAN EPIGLOTIS, TELINGA TENGAH, ISPA DAN LARINGOTRAKEITIS SEDANG
4.947.031
705
U-4-13-iii
PERADANGAN EPIGLOTIS, TELINGA TENGAH, ISPA DAN LARINGOTRAKEITIS BERAT
5.775.375
Deskripsi (INA-CBG)
Tarif
INA-CBG
- 1066 No
Kode
INA-CBG
706
U-4-14-i
5.414.270
707
U-4-14-ii
6.497.123
708
U-4-14-iii
709
U-4-15-i
DIAGNOSIS TENGGOROKAN, MULUT, HIDUNG & TELINGA LAIN-LAIN (RINGAN)
4.331.416
710
U-4-15-ii
DIAGNOSIS TENGGOROKAN, MULUT, HIDUNG & TELINGA LAIN-LAIN (SEDANG)
5.414.270
711
U-4-15-iii
DIAGNOSIS TENGGOROKAN, MULUT, HIDUNG & TELINGA LAIN-LAIN (BERAT)
7.581.447
712
V-1-10-i
PROSEDUR PENGANGKATAN PROSTAT KOMPLEK RINGAN
12.662.164
713
V-1-10-ii
PROSEDUR PENGANGKATAN PROSTAT KOMPLEK SEDANG
14.586.987
714
V-1-10-iii
PROSEDUR PENGANGKATAN PROSTAT KOMPLEK BERAT
27.715.275
715
V-1-11-i
14.586.987
716
V-1-11-ii
16.279.322
717
V-1-11-iii
24.107.184
718
V-1-12-i
PROSEDUR PADA SKROTUM DAN PROSTAT KOMPLEK-MODERAT (RINGAN)
8.100.288
719
V-1-12-ii
PROSEDUR PADA SKROTUM DAN PROSTAT KOMPLEK-MODERAT (SEDANG)
30.956.608
720
V-1-12-iii
PROSEDUR PADA SKROTUM DAN PROSTAT KOMPLEK-MODERAT (BERAT)
36.144.660
721
V-1-13-i
PROSEDUR PADA SKROTUM DAN PROSTAT NON KOMPLEK (RINGAN)
12.277.411
722
V-1-13-ii
PROSEDUR PADA SKROTUM DAN PROSTAT NON KOMPLEK (SEDANG)
23.330.603
723
V-1-13-iii
PROSEDUR PADA SKROTUM DAN PROSTAT NON KOMPLEK (BERAT)
35.008.769
724
V-1-14-i
PROSEDUR PENGANGKATAN PROSTAT MELALUI URETRA RINGAN
14.800.561
725
V-1-14-ii
PROSEDUR PENGANGKATAN PROSTAT MELALUI URETRA SEDANG
21.526.148
726
V-1-14-iii
PROSEDUR PENGANGKATAN PROSTAT MELALUI URETRA BERAT
29.261.667
727
V-1-15-i
6.977.641
728
V-1-15-ii
13.291.047
729
V-1-15-iii
22.724.635
730
V-4-10-i
TUMOR PADA SISTEM REPRODUKSI LAKI-LAKI RINGAN
11.235.763
731
V-4-10-ii
TUMOR PADA SISTEM REPRODUKSI LAKI-LAKI SEDANG
14.512.330
732
V-4-10-iii
TUMOR PADA SISTEM REPRODUKSI LAKI-LAKI BERAT
27.735.609
733
V-4-11-i
DIAGNOSIS SISTEM REPRODUKSI LAKI-LAKI SELAIN TUMOR (RINGAN)
5.713.806
734
V-4-11-ii
DIAGNOSIS SISTEM REPRODUKSI LAKI-LAKI SELAIN TUMOR (SEDANG)
8.348.784
735
V-4-11-iii
736
W-1-01-i
737
W-1-01-ii
738
W-1-01-iii
739
W-1-10-i
Deskripsi (INA-CBG)
DIAGNOSIS SISTEM REPRODUKSI LAKI-LAKI SELAIN TUMOR (BERAT)

PROSEDUR OPERASI PENGANGKATAN RAHIM DAN VULVA RADIKAL & EVISCERASI
RINGAN
SEDANG
BERAT
Tarif
INA-CBG
10.883.809
13.774.940
16.801.388
20.236.475
44.698.353
4.679.166
- 1067 No
Kode
INA-CBG
740
W-1-10-ii
741
W-1-10-iii
742
W-1-11-i
PROSEDUR DILATASI, KURET, INTRAUTERIN & SERVIK RINGAN
4.860.098
743
W-1-11-ii
PROSEDUR DILATASI, KURET, INTRAUTERIN & SERVIK SEDANG
9.373.314
744
W-1-11-iii
PROSEDUR DILATASI, KURET, INTRAUTERIN & SERVIK BERAT
745
W-1-12-i
PROSEDUR OPERASI MEMBUKA TUBA YANG TERHALANG/TERGANGGU RINGAN
4.416.129
746
W-1-12-ii
PROSEDUR OPERASI MEMBUKA TUBA YANG TERHALANG/TERGANGGU SEDANG
5.021.054
747
W-1-12-iii
PROSEDUR OPERASI MEMBUKA TUBA YANG TERHALANG/TERGANGGU BERAT
7.712.973
748
W-1-13-i
PROSEDUR INTERUPSI TUBA DENGAN ENDOSKOP RINGAN
5.112.091
749
W-1-13-ii
PROSEDUR INTERUPSI TUBA DENGAN ENDOSKOP SEDANG
5.550.257
750
W-1-13-iii
PROSEDUR INTERUPSI TUBA DENGAN ENDOSKOP BERAT
7.455.020
751
W-1-20-i
14.321.750
752
W-1-20-ii
20.145.690
753
W-1-20-iii
25.449.685
754
W-1-30-i
PROSEDUR PADA VAGINA, SERVIK & VULVA RINGAN
7.818.239
755
W-1-30-ii
PROSEDUR PADA VAGINA, SERVIK & VULVA SEDANG
12.470.496
756
W-1-30-iii
PROSEDUR PADA VAGINA, SERVIK & VULVA BERAT
33.162.118
757
W-4-10-i
5.830.448
758
W-4-10-ii
7.880.503
759
W-4-10-iii
760
W-4-11-i
5.414.270
761
W-4-11-ii
8.662.831
762
W-4-11-iii
763
W-4-12-i
GANGGUAN MENSTRUASI & SISTEM REPRODUKSI WANITA LAIN-LAIN (RINGAN)
4.331.416
764
W-4-12-ii
GANGGUAN MENSTRUASI & SISTEM REPRODUKSI WANITA LAIN-LAIN (SEDANG)
5.955.696
765
W-4-12-iii
GANGGUAN MENSTRUASI & SISTEM REPRODUKSI WANITA LAIN-LAIN (BERAT)
6.827.168
766
W-4-13-i
ABORTUS RINGAN
2.375.399
767
W-4-13-ii
ABORTUS SEDANG
3.248.562
768
W-4-13-iii
ABORTUS BERAT
4.331.416
769
W-4-14-i
3.248.562
770
W-4-14-ii
4.295.988
771
W-4-14-iii
5.257.423
772
W-4-15-i
2.785.306
773
W-4-15-ii
3.097.791
Deskripsi (INA-CBG)
Tarif
INA-CBG
8.732.092
14.282.932
17.504.384
17.325.662
10.527.907
- 1068 No
Kode
INA-CBG
774
W-4-15-iii
4.289.186
775
W-4-16-i
3.248.562
776
W-4-16-ii
4.427.262
777
W-4-16-iii
5.905.296
778
W-4-17-i
2.728.097
779
W-4-17-ii
4.331.416
780
W-4-17-iii
8.194.177
781
Z-4-10-i
REHABILITASI RINGAN
7.432.196
782
Z-4-10-ii
REHABILITASI SEDANG
9.865.168
783
Z-4-10-iii
REHABILITASI BERAT
784
Z-4-11-i
6.670.419
785
Z-4-11-ii
8.029.710
786
Z-4-11-iii
787
Z-4-12-i
FAKTOR-FAKTOR YANG MEMPENGARUHI STATUS KESEHATAN LAIN-LAIN (RINGAN)
3.248.562
788
Z-4-12-ii
FAKTOR-FAKTOR YANG MEMPENGARUHI STATUS KESEHATAN LAIN-LAIN (SEDANG)
6.805.470
789
Z-4-12-iii
FAKTOR-FAKTOR YANG MEMPENGARUHI STATUS KESEHATAN LAIN-LAIN (BERAT)
8.648.675
Deskripsi (INA-CBG)
Tarif
INA-CBG
14.014.412
12.553.346
No
Kode
INA-CBG
B-2-10-0
2.213.577
B-2-11-0
2.871.356
B-2-12-0
PROSEDUR KOLESISTEKTOMI TANPA LAPAROSKOPI
5.339.665
B-2-13-0
PROSEDUR LAIN-LAIN PADA HEPATOBILIARI & PANKREAS
4.412.715
B-2-14-0
PROSEDUR KOLESISTEKTOMI DENGAN LAPAROSKOPI
3.686.443
B-3-10-0
PROSEDUR PADA PERKUTAN HATI & SALURAN EMPEDU
1.292.483
B-3-11-0
2.882.068
B-3-12-0
PROSEDUR LAIN-LAIN PADA SISTEM HEPATOBILIARI DAN PANKREAS
C-3-10-0
1.615.356
10
C-3-11-0
KEMOTERAPI PADA TUMOR PARU & KANDUNG KEMIH
2.554.748
11
C-3-12-0
579.156
12
C-3-13-0
KEMOTERAPI PADA TUMOR PAYUDARA ATAU OVARIUM
562.400
13
C-3-14-0
KEMOTERAPI PADA TUMOR GASTROINTESTINAL
4.787.721
14
C-3-15-0
KEMOTERAPI PADA TUMOR MELANOMA, GINJAL ATAU PROSTAT
4.388.137
15
C-3-16-0
995.124
16
C-3-17-0
KEMOTERAPI PADA TUMOR KEPALA ATAU LEHER
660.136
17
C-3-18-0
292.676
18
C-3-19-0
KEMOTERAPI PADA TUMOR LIMFOMA, MYELOMA ATAU TESTIS
413.903
19
C-3-20-0
20
C-3-21-0
21
C-3-22-0
22
C-3-23-0
23
D-2-10-0
2.845.897
24
D-2-11-0
PROSEDUR LIMPA
3.563.549
25
D-2-21-0
PROSEDUR BESAR PADA NODUL LIMPA DAN TYMUS
2.988.808
26
D-2-22-0
PROSEDUR KECIL PADA NODUL LIMPA DAN TYMUS
655.954
27
D-3-10-0
PROSEDUR TRANSFUSI & TERAPI SUMSUM TULANG
475.123
28
D-3-11-0
PROSEDUR DIAGNOSTIK DARAH DAN ORGAN PEMBENTUK DARAH
29
E-2-10-0
731.737
30
E-2-21-0
PROSEDUR BESAR PADA KELENJAR TIROID DAN PARATIROID
530.484
31
E-2-22-0
PROSEDUR KECIL PADA KELENJAR TIROID,PARATIROID DAN SALURAN

THYROGLOSSAL
530.484
32
E-3-10-0
PROSEDUR DIAGNOSTIK PADA KELENJAR ENDOKRIN
616.919
33
F-3-10-0
TERAPI SHOCK
860.582
Deskripsi (INA-CBG)
Tarif
INA-CBG
592.170
8.242.893
472.337
2.073.812
335.912
1.233.557
- 1070 No
Kode
INA-CBG
34
F-5-10-0
35
F-5-11-0
TERAPI KELOMPOK
695.340
36
F-5-12-0
889.805
37
F-5-13-0
753.606
38
F-5-14-0
PSIKOTHERAPI INDIVIDU DEWASA BUKAN AKUT
505.569
39
F-5-15-0
PENGOBATAN INDIVIDU KETERBELAKANGAN MENTAL
474.289
40
F-5-16-0
PSIKOTHERAPI INDIVIDU PADA KANAK-KANAK MASALAH KESEHATAN MENTAL
494.017
41
G-2-10-0
PROSEDUR KRANIOTOMI
416.000
42
G-2-11-0
3.606.067
43
G-2-12-0
PROSEDUR PADA PEMBULUH DARAH EKSTRAKRANIAL
5.226.078
44
G-2-13-0
1.282.074
45
G-2-21-0
2.338.286
46
G-2-22-0
2.122.194
47
G-2-31-0
3.501.804
48
G-2-32-0
1.795.022
49
G-3-10-0
712.456
50
G-3-11-0
948.854
51
G-3-12-0
1.554.714
52
G-3-13-0
1.554.891
53
H-2-21-0
2.040.564
54
H-2-22-0
530.484
55
H-2-23-0
530.484
56
H-2-31-0
PROSEDUR BESAR PADA SEGMEN ANTERIOR MATA
57
H-2-32-0
PROSEDUR SEDANG PADA SEGMEN ANTERIOR MATA
351.782
58
H-2-33-0
PROSEDUR KECIL PADA SEGMEN ANTERIOR MATA
530.484
59
H-2-34-0
PROSEDUR BESAR PADA SEGMEN POSTERIOR MATA
1.516.361
60
H-2-35-0
PROSEDUR KECIL PADA SEGMEN POSTERIOR MATA
499.676
61
H-2-36-0
2.697.131
62
H-2-37-0
PROSEDUR PHOTOKOAGULASI DAN KRIOTHERAPI PADA RETINA
2.871.215
63
H-3-10-0
998.973
64
H-3-11-0
525.349
65
H-3-12-0
548.491
66
H-3-13-0
PROSEDUR DIAGNOSTIK & IMAGING PADA MATA
532.552
67
I-2-11-0
PEMASANGAN/PENYISIPAN DEFIBRILATOR JANTUNG & SISTEM BANTU JANTUNG
Deskripsi (INA-CBG)
Tarif
INA-CBG
1.054.491
3.380.024
6.141.458
- 1071 No
Kode
INA-CBG
68
I-2-12-0
PROSEDUR BESAR PADA PEMBULUH DARAH TORASIK
4.318.115
69
I-2-13-0
PROSEDUR BESAR PADA PEMBULUH DARAH ABDOMEN
5.488.064
70
I-2-14-0
PROSEDUR PEMASANGAN/PENYISIPAN ALAT PACU PERMANEN PADA JANTUNG
9.712.706
71
I-2-15-0
72
I-2-16-0
PROSEDUR REVISI DEFIBRILATOR DAN ALAT PACU JANTUNG TIDAK TERMASUK

PENGGANTIAN ALAT
6.134.802
73
I-2-17-0
PROSEDUR LIGASI DAN STRIPPING PEMBULUH DARAH VENA
2.022.468
74
I-2-21-0
4.735.195
75
I-2-22-0
4.459.016
76
I-2-23-0
77
I-2-31-0
PEMASANGAN ATAU PENGGANTIAN ALAT DEFIBRILATOR JANTUNG
7.097.009
78
I-2-32-0
PEMASANGAN ATAU PENGGANTIAN ALAT PACU JANTUNG
9.280.381
79
I-2-41-0
6.222.610
80
I-2-42-0
PROSEDUR ANGIOPLASTI PEMBULUH DARAH KORONER DAN KARDIOVASKULAR

PERKUTAN LAIN
7.234.813
81
I-3-10-0
PROSEDUR RESUSITASI
918.395
82
I-3-11-0
484.727
83
I-3-12-0
84
I-3-13-0
925.228
85
I-3-14-0
593.040
86
I-3-15-0
PROSEDUR PENGAWASAN FUNGSI KARDIOVASKULAR
525.349
87
J-2-10-0
PROSEDUR BESAR PADA SISTEM SALURAN PERNAFASAN
88
J-2-21-0
PROSEDUR VENTILASI MEKANIKAL JANGKA PENDEK
89
J-2-22-0
2.642.257
90
J-2-31-0
3.427.243
91
J-2-32-0
2.550.438
92
J-3-10-0
530.484
93
J-3-11-0
PROSEDUR PEMASANGAN/PENYISIPAN TUBE PADA DADA
94
J-3-12-0
579.156
95
J-3-13-0
852.373
96
J-3-14-0
904.887
97
J-3-15-0
793.513
98
J-3-16-0
904.887
99
J-3-17-0
PROSEDUR LAIN-LAIN PADA SISTEM SALURAN PERNAFASAN
530.484
100
K-2-10-0
1.526.915
101
K-2-11-0
3.260.585
Deskripsi (INA-CBG)
Tarif
INA-CBG
584.103
912.524
2.817.050
3.252.623
524.322
1.499.053
- 1072 No
Kode
INA-CBG
102
K-2-12-0
PROSEDUR PADA HERNIA TIDAK TERMASUK HERNIA INGUINALIS DAN FEMORALIS
2.502.920
103
K-2-13-0
4.073.638
104
K-2-14-0
PROSEDUR PADA HERNIA INGUINALIS DAN FEMORALIS
530.484
105
K-2-21-0
PROSEDUR BESAR PADA USUS HALUS DAN USUS BESAR
530.484
106
K-2-22-0
PROSEDUR BESAR PADA GASTROINTESTINAL ATAS
6.817.983
107
K-2-31-0
PROSEDUR SEDANG PADA GASTROINTESTINAL ATAS
2.292.541
108
K-2-32-0
PROSEDUR LAIN-LAIN PADA GASTROINTESTINAL ATAS
109
K-2-41-0
110
K-2-42-0
PROSEDUR LAPAROTOMI & GASTROINTESTINAL LAINNYA
111
K-2-51-0
112
K-2-52-0
912.524
113
K-2-53-0
530.484
114
K-3-10-0
PROSEDUR KECIL LAIN-LAIN PADA GASTROINTESTINAL
115
K-3-11-0
606.892
116
K-3-12-0
615.465
117
K-3-13-0
530.484
118
K-3-14-0
PROSEDUR ENDOSKOPI BESAR PADA GASTROINTESTINAL ATAS
1.421.709
119
K-3-15-0
PROSEDUR ENDOSKOPI KECIL PADA GASTROINTESTINAL ATAS
686.563
120
K-3-16-0
PROSEDUR LAIN-LAIN PADA GASTROINTESTINAL
909.740
121
L-2-21-0
PROSEDUR BESAR PEMINDAHAN KULIT PADA LUKA BAKAR
3.127.718
122
L-2-22-0
PROSEDUR KECIL PEMINDAHAN KULIT PADA LUKA BAKAR
2.004.845
123
L-2-31-0
PROSEDUR BESAR PEMINDAHAN KULIT TANPA LUKA BAKAR
904.887
124
L-2-32-0
PROSEDUR KECIL PEMINDAHAN KULIT TANPA LUKA BAKAR
912.524
125
L-2-41-0
126
L-2-42-0
PROSEDUR LAIN-LAIN PADA KULIT DAN JARINGAN BAWAH KULIT
127
L-2-51-0
4.090.899
128
L-2-52-0
PROSEDUR BESAR PADA PAYUDARA TANPA PENGANGKATAN PAYUDARA
3.129.673
129
L-2-53-0
PROSEDUR KECIL PADA PAYUDARA TANPA PENGANGKATAN PAYUDARA
530.484
130
L-3-10-0
721.504
131
L-3-11-0
700.630
132
L-3-12-0
533.597
133
M-2-10-0
PROSEDUR REKONTRUKSI TULANG KRANIAL DAN WAJAH
4.185.288
134
M-2-21-0
PROSEDUR BESAR PADA SENDI PANGGUL DAN PAHA
3.748.215
135
M-2-22-0
PROSEDUR KECIL PADA SENDI PANGGUL DAN PAHA
912.524
Deskripsi (INA-CBG)
Tarif
INA-CBG
530.484
2.525.281
721.504
1.673.404
1.009.475
2.732.446
612.844
- 1073 No
Kode
INA-CBG
136
M-2-31-0
PROSEDUR BUNION
137
M-2-32-0
721.504
138
M-2-41-0
PROSEDUR EKSISI, INSISI DAN ARTHROTOMI TULANG
721.504
139
M-2-42-0
248.650
140
M-2-51-0
530.484
141
M-2-52-0
530.484
142
M-2-61-0
PROSEDUR ARTROSKOPI
143
M-2-62-0
144
M-2-63-0
PROSEDUR INSISI, BIOPSI DAN GRAFT PADA TULANG
2.614.246
145
M-2-64-0
PROSEDUR BESAR PADA TULANG KEPALA & WAJAH
3.565.291
146
M-2-65-0
PROSEDUR KECIL PADA TULANG KEPALA & WAJAH
530.484
147
M-2-71-0
PROSEDUR BESAR PADA LUTUT & TUNGKAI BAWAH
2.632.122
148
M-2-72-0
PROSEDUR KECIL PADA LUTUT & TUNGKAI BAWAH
2.540.110
149
M-2-81-0
3.787.845
150
M-2-82-0
2.751.626
151
M-2-83-0
PROSEDUR BESAR PADA TANGAN & PERGELANGAN TANGAN
530.484
152
M-2-84-0
PROSEDUR KECIL PADA TANGAN & PERGELANGAN TANGAN
530.484
153
M-3-10-0
154
M-3-11-0
PROSEDUR DIAGNOSTIK DAN TERAPEUTIK MUSKULOSKELETAL
155
M-3-12-0
156
M-3-13-0
157
M-3-14-0
PROSEDUR REDUKSI FRAKTUR WAJAH TERTUTUP
158
M-3-15-0
466.054
159
M-3-16-0
PROSEDUR THERAPI FISIK DAN PROSEDUR KECIL MUSKULOSKLETAL
530.484
160
M-3-17-0
579.156
161
N-2-11-0
7.008.214
162
N-2-12-0
PROSEDUR MEMBUAT BARU, MEREVISI DAN MEMINDAHKAN ALAT DIALISIS
4.054.183
163
N-2-21-0
EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY (ESWL) PADA SALURAN KEMIH
4.032.813
164
N-2-22-0
912.524
165
N-2-23-0
912.524
166
N-2-24-0
2.948.972
167
N-2-31-0
PROSEDUR BESAR PADA KANDUNG KEMIH DAN URETHRA
2.482.556
168
N-2-32-0
PROSEDUR KECIL PADA KANDUNG KEMIH DAN URETHRA
912.524
169
N-2-41-0
PROSEDUR BESAR PADA URETHRA DAN TRANSURETHRA
912.524
Deskripsi (INA-CBG)
Tarif
INA-CBG
2.276.664
2.600.180
530.484
1.514.104
839.478
1.898.416
618.935
1.057.864
- 1074 No
Kode
INA-CBG
170
N-2-42-0
PROSEDUR KECIL PADA URETHRA DAN TRANSURETHRA
171
N-3-10-0
172
N-3-11-0
PROSEDUR DIAGNOSTIK LAIN PADA STUDI SALURAN KEMIH
173
N-3-12-0
PROSEDUR CYSTOSCOPI & PROSEDUR KECIL ENDOSKOPI SALURAN KEMIH
817.014
174
N-3-13-0
PROSEDUR BESAR ENDOSKOPI PADA SALURAN KEMIH
912.524
175
N-3-14-0
PROSEDUR KECIL ENDOSKOPI PADA SALURAN KEMIH
785.177
176
N-3-15-0
PROSEDUR DIALISIS
177
O-7-10-0
PROSEDUR PERSALINAN DENGAN BEDAH CAESAR
178
O-7-11-0
179
O-7-12-0
180
O-7-13-0
PROSEDUR PERSALINAN MELALUI VAGINAL/JALAN LAHIR
374.640
181
P-9-10-0
NEONATAL, MENINGGAL DAN DITRANSFER KE FASILITAS PERAWATAN PASIEN

AKUT LAIN
499.676
182
P-9-11-0
499.676
183
P-9-12-0
499.676
184
P-9-13-0
499.676
185
P-9-14-0
499.676
186
P-9-15-0
NEONATAL, BBL GROUP-5 DENGAN SINDROM ASPIRASI
318.504
187
P-9-16-0
NEONATAL, BBL GROUP-5 DENGAN KONGENITAL/INFEKSI PERINATAL
499.676
188
P-9-17-0
497.526
189
Q-5-10-0
651.236
190
Q-5-11-0
488.084
191
Q-5-12-0
GIGI
430.184
192
Q-5-13-0
MEDICAL CHECK-UP
326.921
193
Q-5-14-0
359.720
194
Q-5-15-0
247.380
195
Q-5-16-0
VAKSINASI
279.596
196
Q-5-17-0
PASANG INFUS
241.843
197
Q-5-18-0
455.224
198
Q-5-19-0
508.914
199
Q-5-20-0
ABORSI MENGANCAM
341.108
200
Q-5-21-0
ABORSI
336.462
201
Q-5-22-0
359.720
202
Q-5-23-0
440.393
203
Q-5-24-0
300.782
Deskripsi (INA-CBG)
PERSALINAN VAGINAL DENGAN STERILISASI DAN ATAU PELEBARAN DAN

KURETASE
PROSEDUR PERSALINAN VAGINAL DENGAN PROSEDUR SELAIN STERILISASI DAN
ATAU PELEBARAN DAN KURETASE
Tarif
INA-CBG
1.543.253
912.524
1.057.290
2.013.393
336.150
1.851.266
674.108
- 1075 No
Kode
INA-CBG
204
Q-5-25-0
469.063
205
Q-5-26-0
BRONKIAL AKUT
663.927
206
Q-5-27-0
472.483
207
Q-5-28-0
383.407
208
Q-5-29-0
GAGAL JANTUNG KONGESTIF DAN KONDISI JANTUNG LAIN-LAIN
1.085.489
209
Q-5-30-0
1.257.965
210
Q-5-31-0
FRAKTUR
448.791
211
Q-5-32-0
SALURAN KEMIH AKUT
519.802
212
Q-5-33-0
HEMATOLOGI AKUT
544.231
213
Q-5-34-0
INFEKSI VIRUS HIV
773.117
214
Q-5-35-0
INFEKSI AKUT
876.694
215
Q-5-36-0
216
Q-5-37-0
CARDIAC ARREST, RESPIRATORY ARREST & SHOCK
520.745
217
Q-5-38-0
PARU AKUT
694.431
218
Q-5-39-0
444.385
219
Q-5-40-0
436.013
220
Q-5-41-0
603.598
221
Q-5-42-0
473.244
222
Q-5-43-0
681.499
223
Q-5-44-0
556.198
224
T-2-10-0
PEMULIHAN ALKOHOL, OBAT DAN ATAU TERAPI DETOKSIKASI
288.491
225
U-2-10-0
3.850.232
226
U-2-11-0
PROSEDUR BESAR LAIN-LAIN PADA KEPALA & LEHER
4.576.429
227
U-2-12-0
503.527
228
U-2-13-0
660.136
229
U-2-14-0
PROSEDUR OPERASI BIBIR SUMBING & LANGIT-LANGIT MULUT
230
U-2-15-0
696.719
231
U-2-21-0
PROSEDUR BESAR PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN
811.569
232
U-2-22-0
PROSEDUR SEDANG PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN
1.568.016
233
U-2-23-0
2.054.607
234
U-2-24-0
1.731.588
235
U-2-25-0
660.136
236
U-2-31-0
530.484
237
U-2-32-0
660.136
Deskripsi (INA-CBG)
Tarif
INA-CBG
1.020.967
1.226.233
- 1076 No
Kode
INA-CBG
238
U-3-10-0
PROSEDUR SEDANG LAIN-LAIN PADA TELINGA, HIDUNG, MULUT DAN

TENGGOROKAN
631.125
239
U-3-11-0
PROSEDUR KECIL LAIN-LAIN PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN
670.058
240
U-3-12-0
PROSEDUR KAUTERISASI & PACKING PADA RONGGA HIDUNG
296.299
241
U-3-13-0
PROSEDUR DIAGNOSTIK LAIN-LAIN PADA TELINGA, HIDUNG, MULUT DAN

TENGGOROKAN
651.288
242
U-3-14-0
PROSEDUR TES FUNGSI PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN
598.399
243
U-3-15-0
PROSEDUR LAIN-LAIN PADA TELINGA, HIDUNG, MULUT DAN TENGGOROKAN
521.857
244
U-3-16-0
PROSEDUR PADA GIGI
588.560
245
V-2-10-0
PROSEDUR BESAR PADA PENGANGKATAN PROSTAT
246
V-2-11-0
PROSEDUR PADA PENIS
247
V-2-12-0
PROSEDUR SEDANG PADA PROSTAT DAN SKROTUM
248
V-2-13-0
PROSEDUR KECIL PADA PROSTAT DAN SKROTUM
912.524
249
V-2-14-0
PENGANGKATAN PROSTAT MELALUI TRANSURETHRAL
912.524
250
V-2-15-0
SIRKUMSISI/SUNAT
499.676
251
V-3-10-0
1.042.107
252
V-3-11-0
PROSEDUR DIAGNOSTIK DAN TERAPEUTIK PADA ALAT GENITAL LAKI-LAKI
2.204.596
253
V-3-12-0
PROSEDUR LAIN PADA ALAT GENITAL LAKI-LAKI
1.272.771
254
W-2-10-0
PROSEDUR ABORSI
255
W-2-11-0
PROSEDUR PELEBARAN, KURETASE DALAM RAHIM & LEHER RAHIM
1.191.060
256
W-2-12-0
PROSEDUR MEMBUKA TUBA YANG TERHALANG/TERGANGGU
2.204.596
257
W-2-13-0
PROSEDUR ENDOSKOPI TUBA YANG TERHALANG/TERGANGGU
258
W-2-21-0
PROSEDUR BESAR PADA FRAKTUR RONGGA PANGGUL TERBUKA
4.431.825
259
W-2-22-0
PROSEDUR KECIL PADA FRAKTUR RONGGA PANGGUL TERBUKA
466.054
260
W-2-23-0
1.555.244
261
W-2-31-0
PROSEDUR PEMBUANGAN RAHIM MELALUI JALAN LAHIR
5.105.394
262
W-2-32-0
PROSEDUR PERBAIKAN CYSTOCELE DAN VULVOVAGINAL INTERMEDIATE
3.580.644
263
W-2-33-0
1.521.821
264
W-2-34-0
265
W-3-10-0
1.257.964
266
W-3-11-0
1.005.580
267
W-3-12-0
268
Z-3-10-0
5.276.350
269
Z-3-11-0
EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY (ESWL) SELAIN URINARI DAN

SALURAN EMPEDU
4.032.813
270
Z-3-12-0
271
Z-3-13-0
PROSEDUR KECIL PELAYANAN PENUNJANG LAIN-LAIN
Deskripsi (INA-CBG)
Tarif
INA-CBG
5.742.084
647.561
2.066.459
466.054
353.578
517.598
466.054
673.382
4.109.163
- 1077 No
Kode
INA-CBG
272
Z-3-14-0
DIAGNOSTIK TIDUR
812.509
273
Z-3-15-0
530.484
274
Z-3-16-0
PROSEDUR MAGNETIC RESONANCE IMAGING (MRI)
275
Z-3-17-0
PENGOBATAN NUKLIR
714.827
276
Z-3-18-0
CT-SCAN KEPALA
688.722
277
Z-3-19-0
CT SCAN LAIN-LAIN
716.826
278
Z-3-20-0
487.531
279
Z-3-21-0
466.054
280
Z-3-22-0
525.433
281
Z-3-23-0
547.285
282
Z-3-24-0
283
Z-3-25-0
478.940
284
Z-3-26-0
541.296
285
Z-3-27-0
PERAWATAN LUKA
516.791
286
Z-3-28-0
IMAGING PAYUDARA
530.484
287
Z-3-29-0
IMAGING LAIN-LAIN
288
Z-3-30-0
FOTOTERAPI
Deskripsi (INA-CBG)
Tarif
INA-CBG
1.702.693
1.075.306
1.528.951
258.030
- 1078 -
VII. TARIF INA-CBG RUMAH SAKIT ANAK DAN BUNDA HARAPAN

KITA TAHUN 2012
a. RawatInap
No
Kode INACBG
A-4-10-i
SEPTIKEMIA RINGAN
3.440.105
A-4-10-ii
SEPTIKEMIA SEDANG
5.879.448
A-4-10-iii
SEPTIKEMIA BERAT
A-4-11-i
9.230.761
A-4-11-ii
14.260.460
A-4-11-iii
23.326.996
A-4-12-i
DEMAM RINGAN
4.035.414
A-4-12-ii
DEMAM SEDANG
5.193.637
A-4-12-iii
DEMAM BERAT
6.157.473
10
A-4-13-i
5.044.268
11
A-4-13-ii
5.689.647
12
A-4-13-iii
7.153.781
13
A-4-14-i
4.035.414
14
A-4-14-ii
5.165.773
15
A-4-14-iii
5.933.347
16
A-4-15-i
INFEKSI HIV RINGAN
6.053.122
17
A-4-15-ii
INFEKSI HIV SEDANG
9.079.683
18
A-4-15-iii
INFEKSI HIV BERAT
11.331.114
19
B-1-01-i
67.108.291
20
B-1-01-ii
74.038.386
21
B-1-01-iii
129.878.565
22
B-1-10-i
8.700.362
23
B-1-10-ii
22.172.713
24
B-1-10-iii
34.631.181
25
B-1-11-i
5.337.123
26
B-1-11-ii
13.396.683
27
B-1-11-iii
16.796.116
28
B-1-12-i
11.384.277
29
B-1-12-ii
24.399.290
Deskripsi (INA-CBG)
Tarif
INA-CBG
10.272.638
- 1079 No
Kode INACBG
30
B-1-12-iii
31
B-1-13-i
7.459.863
32
B-1-13-ii
12.151.035
33
B-1-13-iii
17.914.034
34
B-1-14-i
10.129.969
35
B-1-14-ii
11.266.570
36
B-1-14-iii
17.625.210
37
B-4-10-i
3.157.192
38
B-4-10-ii
5.044.268
39
B-4-10-iii
6.920.227
40
B-4-11-i
6.842.848
41
B-4-11-ii
10.402.838
42
B-4-11-iii
11.204.218
43
B-4-12-i
6.004.130
44
B-4-12-ii
8.512.380
45
B-4-12-iii
46
B-4-13-i
6.053.122
47
B-4-13-ii
7.061.975
48
B-4-13-iii
49
B-4-14-i
6.053.122
50
B-4-14-ii
7.061.975
51
B-4-14-iii
9.421.385
52
C-4-10-i
5.289.282
53
C-4-10-ii
11.097.390
54
C-4-10-iii
LEUKEMIA AKUT BERAT
19.168.219
55
C-4-11-i
6.053.122
56
C-4-11-ii
8.070.829
57
C-4-11-iii
58
C-4-12-i
RADIOTERAPI RINGAN
4.035.414
59
C-4-12-ii
RADIOTERAPI SEDANG
9.969.890
60
C-4-12-iii
RADIOTERAPI BERAT
61
C-4-13-i
KEMOTERAPI RINGAN
3.909.624
62
C-4-13-ii
KEMOTERAPI SEDANG
7.341.079
63
C-4-13-iii
KEMOTERAPI BERAT
Deskripsi (INA-CBG)
Tarif
INA-CBG
29.694.855
18.437.720
12.754.731
12.610.670
20.240.875
10.136.593
- 1080 No
Kode INACBG
64
C-4-14-i
5.044.268
65
C-4-14-ii
7.061.975
66
C-4-14-iii
10.460.074
67
D-1-10-i
42.941.596
68
D-1-10-ii
65.403.344
69
D-1-10-iii
88.639.402
70
D-1-11-i
8.154.083
71
D-1-11-ii
20.656.847
72
D-1-11-iii
32.616.332
73
D-1-20-i
10.872.111
74
D-1-20-ii
24.462.249
75
D-1-20-iii
39.679.196
76
D-4-10-i
3.876.263
77
D-4-10-ii
7.739.406
78
D-4-10-iii
79
D-4-11-i
4.896.019
80
D-4-11-ii
7.620.384
81
D-4-11-iii
82
D-4-12-i
5.174.457
83
D-4-12-ii
7.177.480
84
D-4-12-iii
85
D-4-13-i
3.891.109
86
D-4-13-ii
5.495.672
87
D-4-13-iii
7.061.975
88
D-4-14-i
4.362.944
89
D-4-14-ii
11.352.006
90
D-4-14-iii
13.541.373
91
E-1-01-i
8.680.080
92
E-1-01-ii
12.146.248
93
E-1-01-iii
28.719.393
94
E-1-10-i
9.856.590
95
E-1-10-ii
11.963.587
96
E-1-10-iii
25.215.719
97
E-1-20-i
10.242.157
Deskripsi (INA-CBG)
Tarif
INA-CBG
10.088.536
11.543.820
11.021.024
- 1081 No
Kode INACBG
98
E-1-20-ii
13.717.714
99
E-1-20-iii
30.394.578
100
E-4-10-i
5.044.268
101
E-4-10-ii
7.061.975
102
E-4-10-iii
103
E-4-11-i
4.035.414
104
E-4-11-ii
7.306.069
105
E-4-11-iii
106
E-4-12-i
4.614.442
107
E-4-12-ii
8.016.155
108
E-4-12-iii
109
E-4-13-i
5.044.268
110
E-4-13-ii
8.357.245
111
E-4-13-iii
112
F-4-10-i
SCHIZOFRENIA RINGAN
5.951.235
113
F-4-10-ii
SCHIZOFRENIA SEDANG
6.609.038
114
F-4-10-iii
SCHIZOFRENIA BERAT
9.784.827
115
F-4-11-i
5.485.597
116
F-4-11-ii
6.391.242
117
F-4-11-iii
DEPRESI MAYOR BERAT
8.195.908
118
F-4-12-i
3.026.561
119
F-4-12-ii
4.321.500
120
F-4-12-iii
9.374.768
121
F-4-13-i
4.433.196
122
F-4-13-ii
5.870.691
123
F-4-13-iii
7.569.506
124
F-4-14-i
DEPRESI RINGAN
3.103.238
125
F-4-14-ii
DEPRESI SEDANG
3.980.531
126
F-4-14-iii
DEPRESI BERAT
5.355.982
127
F-4-15-i
4.035.414
128
F-4-15-ii
6.053.122
129
F-4-15-iii
7.972.333
130
F-4-16-i
7.946.617
131
F-4-16-ii
9.237.744
Deskripsi (INA-CBG)
Tarif
INA-CBG
13.712.981
13.090.577
14.201.714
14.460.144
- 1082 No
Kode INACBG
132
F-4-16-iii
133
F-4-17-i
2.044.728
134
F-4-17-ii
5.992.903
135
F-4-17-iii
6.393.987
136
F-4-18-i
6.887.860
137
F-4-18-ii
7.578.591
138
F-4-18-iii
139
F-4-19-i
5.282.339
140
F-4-19-ii
6.764.171
141
F-4-19-iii
8.421.483
142
G-1-01-i
18.715.332
143
G-1-01-ii
31.677.954
144
G-1-01-iii
61.324.981
145
G-1-10-i
8.380.894
146
G-1-10-ii
11.831.739
147
G-1-10-iii
14.023.138
148
G-1-11-i
9.667.612
149
G-1-11-ii
19.853.169
150
G-1-11-iii
41.570.731
151
G-1-12-i
8.154.083
152
G-1-12-ii
17.212.980
153
G-1-12-iii
30.359.922
154
G-1-13-i
2.209.772
155
G-1-13-ii
5.935.204
156
G-1-13-iii
157
G-1-20-i
9.474.017
158
G-1-20-ii
12.799.708
159
G-1-20-iii
31.338.579
160
G-1-30-i
12.083.256
161
G-1-30-ii
31.538.457
162
G-1-30-iii
40.599.740
163
G-4-10-i
5.740.734
164
G-4-10-ii
7.061.975
165
G-4-10-iii
9.680.975
Deskripsi (INA-CBG)
Tarif
INA-CBG
12.330.846
11.683.059
13.392.319
- 1083 No
Kode INACBG
166
G-4-11-i
8.961.751
167
G-4-11-ii
10.395.631
168
G-4-11-iii
15.234.977
169
G-4-12-i
6.702.601
170
G-4-12-ii
8.445.277
171
G-4-12-iii
172
G-4-13-i
4.035.414
173
G-4-13-ii
7.061.975
174
G-4-13-iii
8.348.257
175
G-4-14-i
6.820.301
176
G-4-14-ii
11.221.697
177
G-4-14-iii
14.049.821
Deskripsi (INA-CBG)
Tarif
INA-CBG
12.265.760
178
G-4-15-i
179
G-4-15-ii
180
G-4-15-iii
181
G-4-16-i
5.044.268
182
G-4-16-ii
7.543.749
183
G-4-16-iii
184
G-4-17-i
6.468.544
185
G-4-17-ii
8.027.748
186
G-4-17-iii
187
G-4-18-i
6.053.122
188
G-4-18-ii
8.070.829
189
G-4-18-iii
9.079.683
190
G-4-19-i
191
G-4-19-ii
192
G-4-19-iii
193
G-4-20-i
3.530.988
194
G-4-20-ii
5.014.006
195
G-4-20-iii
8.550.055
196
G-4-21-i
3.671.490
197
G-4-21-ii
5.103.371
198
G-4-21-iii
8.958.435
199
G-4-22-i
3.791.900

RINGAN
SEDANG
BERAT
6.053.122
7.673.995
11.616.378
13.690.556
13.454.572
5.044.268
10.222.887
15.249.303
- 1084 No
Kode INACBG
200
G-4-22-ii
4.853.632
201
G-4-22-iii
5.687.850
202
G-4-23-i
4.035.414
203
G-4-23-ii
5.044.268
204
G-4-23-iii
7.210.424
205
G-4-24-i
4.035.414
206
G-4-24-ii
5.044.268
207
G-4-24-iii
TRAUMA KEPALA BERAT
208
G-4-25-i
GEGAR OTAK RINGAN
3.440.721
209
G-4-25-ii
GEGAR OTAK SEDANG
4.331.943
210
G-4-25-iii
GEGAR OTAK BERAT
5.740.741
211
G-4-26-i
6.053.122
212
G-4-26-ii
7.061.975
213
G-4-26-iii
214
H-1-20-i
5.204.891
215
H-1-20-ii
9.491.708
216
H-1-20-iii
217
H-1-30-i
5.096.084
218
H-1-30-ii
5.809.536
219
H-1-30-iii
9.693.001
220
H-4-10-i
6.053.122
221
H-4-10-ii
10.088.536
222
H-4-10-iii
16.447.293
223
H-4-11-i
4.035.414
224
H-4-11-ii
4.605.174
225
H-4-11-iii
6.584.969
226
H-4-12-i
5.131.275
227
H-4-12-ii
6.950.648
228
H-4-12-iii
11.596.682
229
I-1-01-i
87.059.232
230
I-1-01-ii
88.974.989
231
I-1-01-iii
140.445.314
232
I-1-02-i
48.299.960
233
I-1-02-ii
62.306.949
Deskripsi (INA-CBG)
Tarif
INA-CBG
10.599.983
13.480.323
12.908.130
- 1085 No
Kode INACBG
234
I-1-02-iii
Deskripsi (INA-CBG)
PROSEDUR OPERASI KARDIOTORASIK KOMPLEKS PADA JANTUNG ANOMALI
RINGAN
SEDANG
Tarif
INA-CBG
76.796.937
235
I-1-03-i
236
I-1-03-ii
237
I-1-03-iii
59.796.609
238
I-1-04-i
32.561.870
239
I-1-04-ii
41.826.301
240
I-1-04-iii
89.164.989
241
I-1-05-i
242
I-1-05-ii
243
I-1-05-iii
244
I-1-06-i
27.039.454
245
I-1-06-ii
40.788.559
246
I-1-06-iii
76.543.431
247
I-1-07-i
35.558.929
248
I-1-07-ii
43.869.162
249
I-1-07-iii
47.860.971
250
I-1-11-i
251
I-1-11-ii
252
I-1-11-iii
253
I-1-12-i
23.103.235
254
I-1-12-ii
32.056.818
255
I-1-12-iii
44.711.693
256
I-1-13-i
13.590.138
257
I-1-13-ii
18.173.900
258
I-1-13-iii
25.863.454
259
I-1-14-i
49.720.548
260
I-1-14-ii
61.795.538
261
I-1-14-iii
80.973.463
262
I-1-15-i
10.872.111
263
I-1-15-ii
28.539.291
264
I-1-15-iii
49.571.688
265
I-1-16-i
266
I-1-16-ii

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
PROSEDUR DEFIBRILATOR JANTUNG DAN PEMASANGAN SISTEM BANTUAN

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT

29.127.261
40.770.415
63.926.418
76.711.702
105.554.818
6.764.175
7.521.087
10.008.274
21.308.806
55.402.896
- 1086 No
Kode INACBG
267
I-1-16-iii

268
I-1-17-i
6.132.215
269
I-1-17-ii
12.702.040
270
I-1-17-iii
20.174.987
271
I-1-20-i
13.590.138
272
I-1-20-ii
19.967.920
273
I-1-20-iii
32.616.332
Deskripsi (INA-CBG)
PROSEDUR PENGGANTIAN ALAT DEFIBRILATOR DAN PACEMAKER JANTUNG

RINGAN
SEDANG
Tarif
INA-CBG
63.905.881
274
I-1-30-i
24.174.951
275
I-1-30-ii
276
I-1-30-iii
77.929.348
277
I-1-40-i
13.590.138
278
I-1-40-ii
22.084.931
279
I-1-40-iii
33.169.042
280
I-4-10-i
8.484.012
281
I-4-10-ii
13.396.407
282
I-4-10-iii
19.325.486
283
I-4-11-i
10.059.820
284
I-4-11-ii
12.449.066
285
I-4-11-iii
23.028.180
286
I-4-12-i
8.811.357
287
I-4-12-ii
12.573.781
288
I-4-12-iii
15.614.150
289
I-4-13-i
290
I-4-13-ii
11.498.909
291
I-4-13-iii
26.230.194
292
I-4-14-i
4.922.411
293
I-4-14-ii
5.759.949
294
I-4-14-iii
8.926.005
295
I-4-15-i
8.070.829
296
I-4-15-ii
10.367.473
297
I-4-15-iii
11.816.425
298
I-4-16-i
6.053.122
299
I-4-16-ii
9.810.026
300
I-4-16-iii
50.288.782
7.915.020
12.358.890
- 1087 No
Kode INACBG
301
I-4-17-i
HIPERTENSI RINGAN
5.044.268
302
I-4-17-ii
HIPERTENSI SEDANG
7.671.604
303
I-4-17-iii
HIPERTENSI BERAT
9.332.873
304
I-4-18-i
7.159.107
305
I-4-18-ii
10.967.272
306
I-4-18-iii
14.785.641
307
I-4-19-i
5.602.939
308
I-4-19-ii
10.227.585
309
I-4-19-iii
12.191.189
310
I-4-20-i
6.799.961
311
I-4-20-ii
7.834.062
312
I-4-20-iii
313
I-4-21-i
9.042.847
314
I-4-21-ii
11.280.365
315
I-4-21-iii
15.388.809
316
I-4-22-i
6.393.071
317
I-4-22-ii
7.514.656
318
I-4-22-iii
319
I-4-23-i
320
I-4-23-ii
321
I-4-23-iii
322
I-4-24-i
5.316.676
323
I-4-24-ii
13.274.269
324
I-4-24-iii
16.782.915
325
J-1-01-i
48.659.928
326
J-1-01-ii
53.001.540
327
J-1-01-iii
78.181.719
328
J-1-02-i
21.896.313
329
J-1-02-ii
23.456.785
330
J-1-02-iii
34.662.444
331
J-1-10-i
8.544.258
332
J-1-10-ii
20.637.487
333
J-1-10-iii
36.541.208
334
J-1-20-i
Deskripsi (INA-CBG)

Tarif
INA-CBG
10.397.105
11.024.376
4.967.713
6.099.207
11.917.294
7.384.973
- 1088 No
Kode INACBG
335
J-1-20-ii
10.740.860
336
J-1-20-iii
16.150.935
337
J-1-30-i
4.980.095
338
J-1-30-ii
27.180.277
339
J-1-30-iii
81.974.522
340
J-4-10-i
6.405.385
341
J-4-10-ii
9.158.932
342
J-4-10-iii
343
J-4-11-i
3.626.064
344
J-4-11-ii
5.047.398
345
J-4-11-iii
7.233.050
346
J-4-12-i
EMBOLI PARU RINGAN
6.179.713
347
J-4-12-ii
EMBOLI PARU SEDANG
8.002.517
348
J-4-12-iii
EMBOLI PARU BERAT
349
J-4-13-i
8.541.703
350
J-4-13-ii
12.556.304
351
J-4-13-iii
20.414.671
352
J-4-14-i
TUMOR PARU RINGAN
6.053.122
353
J-4-14-ii
TUMOR PARU SEDANG
9.750.806
354
J-4-14-iii
TUMOR PARU BERAT
355
J-4-15-i
6.053.122
356
J-4-15-ii
7.175.439
357
J-4-15-iii
9.794.782
358
J-4-16-i
5.044.268
359
J-4-16-ii
7.061.975
360
J-4-16-iii
361
J-4-17-i
5.044.268
362
J-4-17-ii
6.053.122
363
J-4-17-iii
364
J-4-18-i
4.035.414
365
J-4-18-ii
5.548.695
366
J-4-18-iii
5.842.436
367
J-4-19-i
7.061.975
368
J-4-19-ii
8.070.829
Deskripsi (INA-CBG)
Tarif
INA-CBG
13.856.096
10.686.553
11.593.213
12.739.060
11.128.316
- 1089 No
Kode INACBG
369
J-4-19-iii
370
J-4-20-i
7.061.975
371
J-4-20-ii
8.070.829
372
J-4-20-iii
373
J-4-21-i
4.035.414
374
J-4-21-ii
9.956.104
375
J-4-21-iii
14.200.661
376
K-1-10-i
10.872.111
377
K-1-10-ii
13.614.840
378
K-1-10-iii
15.945.322
379
K-1-11-i
8.388.476
380
K-1-11-ii
11.013.056
381
K-1-11-iii
27.948.968
382
K-1-12-i
4.512.358
383
K-1-12-ii
5.880.998
384
K-1-12-iii
385
K-1-13-i
5.125.420
386
K-1-13-ii
8.952.636
387
K-1-13-iii
9.574.522
388
K-1-14-i
8.282.982
389
K-1-14-ii
9.729.301
390
K-1-14-iii
23.956.359
391
K-1-20-i
16.071.415
392
K-1-20-ii
22.431.457
393
K-1-20-iii
47.914.651
394
K-1-30-i
10.579.005
395
K-1-30-ii
20.617.807
396
K-1-30-iii
30.386.770
397
K-1-40-i
10.627.888
398
K-1-40-ii
11.694.935
399
K-1-40-iii
19.394.923
400
K-1-50-i
8.106.514
401
K-1-50-ii
10.498.318
402
K-1-50-iii
PROSEDUR ANAL BERAT
14.904.820
Deskripsi (INA-CBG)
Tarif
INA-CBG
12.643.900
19.465.223
11.698.542
- 1090 No
Kode INACBG
403
K-4-10-i
6.140.101
404
K-4-10-ii
8.070.829
405
K-4-10-iii
406
K-4-11-i
4.035.414
407
K-4-11-ii
6.053.122
408
K-4-11-iii
409
K-4-12-i
4.035.414
410
K-4-12-ii
5.409.818
411
K-4-12-iii
Deskripsi (INA-CBG)

(RINGAN)
(SEDANG)
(BERAT)
Tarif
INA-CBG
33.905.100
11.000.703
12.983.177
412
K-4-13-i
6.053.122
413
K-4-13-ii
414
K-4-13-iii
415
K-4-14-i
5.044.268
416
K-4-14-ii
6.826.890
417
K-4-14-iii
418
K-4-15-i
5.044.268
419
K-4-15-ii
9.484.600
420
K-4-15-iii
421
K-4-16-i
5.044.268
422
K-4-16-ii
6.053.122
423
K-4-16-iii
7.061.975
424
K-4-17-i
3.641.772
425
K-4-17-ii
5.283.204
426
K-4-17-iii
7.031.405
427
K-4-18-i
4.035.414
428
K-4-18-ii
6.053.122
429
K-4-18-iii
7.411.034
430
L-1-20-i
17.235.017
431
L-1-20-ii
19.102.845
432
L-1-20-iii
59.059.547
433
L-1-30-i
16.807.187
434
L-1-30-ii
24.345.265
435
L-1-30-iii
25.676.658
436
L-1-40-i
7.840.283
12.823.272
10.326.323
13.494.878
6.786.253
- 1091 No
Kode INACBG
437
L-1-40-ii
15.273.819
438
L-1-40-iii
25.885.087
439
L-1-50-i
13.547.673
440
L-1-50-ii
23.409.521
441
L-1-50-iii
29.155.037
442
L-4-10-i
6.053.122
443
L-4-10-ii
7.061.975
444
L-4-10-iii
445
L-4-11-i
5.137.305
446
L-4-11-ii
7.038.017
447
L-4-11-iii
448
L-4-12-i
6.053.122
449
L-4-12-ii
7.969.418
450
L-4-12-iii
451
L-4-13-i
3.409.251
452
L-4-13-ii
4.035.414
453
L-4-13-iii
5.896.909
454
L-4-14-i
4.035.414
455
L-4-14-ii
6.053.122
456
L-4-14-iii
8.492.405
Deskripsi (INA-CBG)

(RINGAN)
(SEDANG)
(BERAT)
Tarif
INA-CBG
12.818.940
19.086.223
14.892.946
457
M-1-01-i
458
M-1-01-ii
459
M-1-01-iii
460
M-1-02-i
12.503.614
461
M-1-02-ii
20.528.556
462
M-1-02-iii
37.176.274
463
M-1-03-i
464
M-1-03-ii
465
M-1-03-iii
466
M-1-04-i
467
M-1-04-ii
468
M-1-04-iii
469
M-1-05-i

RINGAN
SEDANG
BERAT
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
19.674.218
21.959.610
30.847.302
33.595.461
40.352.945
42.129.429
8.248.259
10.574.183
13.231.596
12.849.204
- 1092 No
Kode INACBG
470
M-1-05-ii
471
M-1-05-iii
472
M-1-07-i
473
M-1-07-ii
474
M-1-07-iii
475
M-1-10-i
8.864.554
476
M-1-10-ii
11.973.746
477
M-1-10-iii
21.171.517
478
M-1-20-i
8.769.334
479
M-1-20-ii
9.934.474
480
M-1-20-iii
481
M-1-30-i
5.245.373
482
M-1-30-ii
10.838.274
483
M-1-30-iii
PROSEDUR KAKI BERAT
16.168.420
484
M-1-40-i
5.906.509
485
M-1-40-ii
10.872.111
486
M-1-40-iii
19.026.194
487
M-1-50-i
7.019.237
488
M-1-50-ii
14.129.889
489
M-1-50-iii
21.744.222
Deskripsi (INA-CBG)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
Tarif
INA-CBG
14.850.236
25.293.997
15.806.723
21.176.069
43.137.660
24.331.169
490
M-1-60-i
5.297.309
491
M-1-60-ii
492
M-1-60-iii
493
M-1-70-i
7.096.264
494
M-1-70-ii
14.479.894
495
M-1-70-iii
23.343.338
496
M-1-80-i
5.717.669
497
M-1-80-ii
8.643.946
498
M-1-80-iii
499
M-4-10-i
4.035.414
500
M-4-10-ii
6.053.122
501
M-4-10-iii
FRAKTUR FEMUR BERAT
502
M-4-11-i
5.044.268
503
M-4-11-ii
10.994.245
10.605.247
18.456.882
19.900.602
11.731.703
- 1093 No
Kode INACBG
504
M-4-11-iii
19.514.527
505
M-4-12-i
4.035.414
506
M-4-12-ii
7.342.432
507
M-4-12-iii
Deskripsi (INA-CBG)

TUMOR MUSKULOSKLETAL,JARINGAN KONEKTIF DAN FRAKTUR PATOLOGIS
RINGAN
SEDANG
Tarif
INA-CBG
13.195.095
508
M-4-13-i
509
M-4-13-ii
510
M-4-13-iii
511
M-4-14-i
7.610.998
512
M-4-14-ii
9.402.231
513
M-4-14-iii
OSTEOMIELITIS BERAT
514
M-4-15-i
4.518.317
515
M-4-15-ii
6.024.803
516
M-4-15-iii
517
M-4-16-i
5.044.268
518
M-4-16-ii
8.070.829
519
M-4-16-iii
520
M-4-17-i
5.044.268
521
M-4-17-ii
7.061.975
522
M-4-17-iii
9.862.423
523
M-4-18-i
5.305.566
524
M-4-18-ii
8.070.829
525
M-4-18-iii
8.997.930
MALFUNGSI, REAKSI ATAU KOMPLIKASI DARI PROSEDUR ATAU PEMASANGAN

ALAT ORTOPEDIK RINGAN
ALAT ORTOPEDIK SEDANG
ALAT ORTOPEDIK BERAT
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
6.684.809
10.088.536
19.885.632
14.083.529
17.150.511
13.466.230
526
M-4-19-i
3.944.760
527
M-4-19-ii
528
M-4-19-iii
529
M-4-20-i
530
M-4-20-ii
531
M-4-20-iii
532
M-4-21-i
533
M-4-21-ii
534
M-4-21-iii
535
N-1-01-i
10.918.740
536
N-1-01-ii
14.767.349
6.644.239
12.976.691
4.035.414
6.053.122
6.708.285
4.035.414
5.044.268
11.520.975
- 1094 No
Kode INACBG
537
N-1-01-iii
31.311.173
538
N-1-11-i
13.516.583
539
N-1-11-ii
18.280.874
540
N-1-11-iii
38.760.891
Deskripsi (INA-CBG)

RINGAN
SEDANG
Tarif
INA-CBG
541
N-1-12-i
542
N-1-12-ii
543
N-1-12-iii
544
N-1-20-i
9.906.423
545
N-1-20-ii
19.640.914
546
N-1-20-iii
22.467.426
547
N-1-30-i
11.785.438
548
N-1-30-ii
17.909.443
549
N-1-30-iii
20.616.723
550
N-1-40-i
10.619.833
551
N-1-40-ii
14.395.563
552
N-1-40-iii
16.742.456
553
N-4-10-i
5.044.268
554
N-4-10-ii
6.060.887
555
N-4-10-iii
556
N-4-11-i
3.466.280
557
N-4-11-ii
6.053.122
558
N-4-11-iii
7.566.402
559
N-4-12-i
4.035.414
560
N-4-12-ii
6.053.122
561
N-4-12-iii
562
N-4-13-i
BATU URIN RINGAN
5.044.268
563
N-4-13-ii
BATU URIN SEDANG
6.053.122
564
N-4-13-iii
BATU URIN BERAT
565
N-4-14-i
566
N-4-14-ii
567
N-4-14-iii
568
N-4-15-i
4.653.265
569
N-4-15-ii
6.385.727
570
N-4-15-iii
7.287.267

7.731.772
17.022.109
31.023.854
14.784.201
10.050.172
14.184.383
3.495.417
5.382.502
8.728.703
- 1095 No
Kode INACBG
571
N-4-16-i
5.044.268
572
N-4-16-ii
8.070.829
573
N-4-16-iii
574
O-6-10-i
5.812.793
575
O-6-10-ii
6.453.086
576
O-6-10-iii
7.952.388
Deskripsi (INA-CBG)

RINGAN
SEDANG
BERAT
Tarif
INA-CBG
16.971.752
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
1.912.632
584
O-6-13-ii
3.466.051
585
O-6-13-iii
4.621.401
586
P-8-01-i
587
P-8-01-ii
588
P-8-01-iii
589
P-8-02-i
590
P-8-02-ii
591
P-8-02-iii
592
P-8-03-i
593
P-8-03-ii
594
P-8-03-iii
595
P-8-04-i
596
P-8-04-ii
597
P-8-04-iii
598
P-8-05-i
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
3.669.693
5.979.007
10.132.561
4.058.392
4.874.119
6.123.632
101.393.172
125.458.190
147.252.746
110.232.206
126.447.687
144.475.523
6.795.069
9.513.097
14.985.285
54.453.763
70.669.244
101.321.908
29.610.191
41.968.453
61.834.882
5.436.055
12.274.057
- 1096 No
Kode INACBG
603
P-8-06-iii
604
P-8-07-i
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
5.004.182
614
P-8-11-ii
23.012.135
615
P-8-11-iii
23.494.243
616
P-8-12-i
5.099.418
617
P-8-12-ii
7.928.710
618
P-8-12-iii
9.354.201
619
P-8-13-i
2.836.839
620
P-8-13-ii
4.877.257
621
P-8-13-iii
7.294.460
Deskripsi (INA-CBG)
BERAT
RINGAN
SEDANG
BERAT
PROSEDUR NEONATAL, BERAT BADAN LAHIR GROUP-5 DENGAN SINDROMA
DISTRES PERNAFASAN RINGAN
DISTRES PERNAFASAN SEDANG
DISTRES PERNAFASAN BERAT
AKUT LAIN RINGAN
AKUT LAIN SEDANG
AKUT LAIN BERAT

RINGAN
SEDANG
BERAT
Tarif
INA-CBG
22.831.146
9.513.097
26.672.434
35.334.360
6.186.110
8.782.054
12.397.563
3.837.856
5.559.693
10.915.315
622
P-8-14-i
4.815.614
623
P-8-14-ii
624
P-8-14-iii
625
P-8-15-i
3.621.492
626
P-8-15-ii
7.238.410
627
P-8-15-iii
8.502.634
628
P-8-16-i
3.278.306
629
P-8-16-ii
4.650.417
630
P-8-16-iii
6.036.470
631
P-8-17-i
2.411.258
632
P-8-17-ii
7.186.996
633
P-8-17-iii
634
S-4-10-i
4.035.414
635
S-4-10-ii
4.535.672
9.832.121
10.785.801
14.506.494
- 1097 No
Kode INACBG
636
S-4-10-iii
6.234.163
637
S-4-11-i
2.348.941
638
S-4-11-ii
3.444.583
639
S-4-11-iii
5.887.165
640
S-4-12-i
3.026.561
641
S-4-12-ii
4.035.414
642
S-4-12-iii
7.881.484
643
S-4-13-i
4.035.414
644
S-4-13-ii
7.133.708
645
S-4-13-iii
646
S-4-14-i
2.458.704
647
S-4-14-ii
5.223.112
648
S-4-14-iii
9.904.881
649
S-4-15-i
1.859.540
650
S-4-15-ii
3.509.586
651
S-4-15-iii
4.545.729
652
S-4-16-i
LUKA BAKAR RINGAN
7.061.975
653
S-4-16-ii
LUKA BAKAR SEDANG
8.949.720
654
S-4-16-iii
LUKA BAKAR BERAT
655
S-4-17-i
3.378.942
656
S-4-17-ii
5.044.268
657
S-4-17-iii
8.225.675
658
T-1-10-i
3.488.000
659
T-1-10-ii
4.684.148
660
T-1-10-iii
8.521.992
Deskripsi (INA-CBG)

PENYALAHGUNAAN & KETERGANTUNGAN ALKOHOL,OPIUM DAN KOKAIN
RINGAN
SEDANG
Tarif
INA-CBG
14.525.136
15.981.115
661
T-4-10-i
1.700.338
662
T-4-10-ii
663
T-4-10-iii
664
T-4-11-i
665
T-4-11-ii
666
T-4-11-iii
3.824.697
667
T-4-12-i
3.530.988
668
T-4-12-ii
5.336.894
669
T-4-12-iii
8.302.289
3.240.467
4.710.759
1.508.880
2.374.548
- 1098 No
Kode INACBG
670
U-1-10-i
3.758.413
671
U-1-10-ii
7.669.272
672
U-1-10-iii
33.117.467
673
U-1-11-i
16.308.166
674
U-1-11-ii
21.744.222
675
U-1-11-iii
32.781.178
676
U-1-12-i
8.942.799
677
U-1-12-ii
24.462.249
678
U-1-12-iii
31.764.694
679
U-1-13-i
10.263.703
680
U-1-13-ii
11.007.174
681
U-1-13-iii
22.308.814
682
U-1-14-i
5.382.936
683
U-1-14-ii
6.605.945
684
U-1-14-iii
7.828.231
685
U-1-15-i
3.161.604
686
U-1-15-ii
4.492.418
687
U-1-15-iii
8.852.490
688
U-1-20-i
8.177.691
689
U-1-20-ii
14.556.290
690
U-1-20-iii
37.859.373
691
U-1-30-i
7.015.033
692
U-1-30-ii
9.470.294
693
U-1-30-iii
694
U-4-10-i
6.529.824
695
U-4-10-ii
16.368.897
696
U-4-10-iii
23.878.657
697
U-4-11-i
4.035.414
698
U-4-11-ii
5.959.689
699
U-4-11-iii
7.511.881
700
U-4-12-i
3.633.709
701
U-4-12-ii
4.221.330
702
U-4-12-iii
6.711.723
U-4-13-i
PERADANGAN EPIGLOTIS, TELINGA TENGAH, ISPA DAN LARINGOTRAKEITIS

RINGAN
3.557.431
703
Deskripsi (INA-CBG)
Tarif
INA-CBG
18.564.500
- 1099 No
Kode INACBG
704
U-4-13-ii

SEDANG
4.201.541
705
U-4-13-iii
5.044.268
706
U-4-14-i
5.044.268
707
U-4-14-ii
6.053.122
708
U-4-14-iii
709
U-4-15-i
4.035.414
710
U-4-15-ii
5.044.268
711
U-4-15-iii
7.063.344
712
V-1-10-i
11.796.854
713
V-1-10-ii
13.590.138
714
V-1-10-iii
24.944.672
715
V-1-11-i
12.477.272
716
V-1-11-ii
14.247.939
717
V-1-11-iii
22.438.127
718
V-1-12-i
6.586.136
719
V-1-12-ii
25.170.024
720
V-1-12-iii
29.388.296
721
V-1-13-i
9.982.448
722
V-1-13-ii
18.969.515
723
V-1-13-iii
32.422.059
724
V-1-14-i
12.033.957
725
V-1-14-ii
17.502.359
726
V-1-14-iii
23.791.911
727
V-1-15-i
5.673.341
728
V-1-15-ii
10.806.609
729
V-1-15-iii
20.292.521
730
V-4-10-i
9.135.510
731
V-4-10-ii
11.799.603
732
V-4-10-iii
22.551.112
733
V-4-11-i
5.044.268
734
V-4-11-ii
7.061.975
735
V-4-11-iii
736
W-1-01-i
737
W-1-01-ii
Deskripsi (INA-CBG)

RINGAN
SEDANG
Tarif
INA-CBG
10.140.029
11.200.050
13.660.778
16.453.759
- 1100 No
Kode INACBG
738
W-1-01-iii

BERAT
739
W-1-10-i
3.804.510
740
W-1-10-ii
7.099.840
741
W-1-10-iii
742
W-1-11-i
3.951.621
743
W-1-11-ii
7.621.201
744
W-1-11-iii
745
W-1-12-i
3.590.641
746
W-1-12-ii
4.082.491
747
W-1-12-iii
6.271.220
748
W-1-13-i
4.762.740
749
W-1-13-ii
5.170.963
750
W-1-13-iii
6.945.557
751
W-1-20-i
11.644.647
752
W-1-20-ii
16.379.944
753
W-1-20-iii
20.692.486
754
W-1-30-i
6.356.810
755
W-1-30-ii
10.139.440
756
W-1-30-iii
26.963.267
757
W-4-10-i
4.740.588
758
W-4-10-ii
7.061.975
759
W-4-10-iii
760
W-4-11-i
5.044.268
761
W-4-11-ii
8.070.829
762
W-4-11-iii
9.808.449
763
W-4-12-i
4.035.414
764
W-4-12-ii
5.548.695
765
W-4-12-iii
6.053.122
766
W-4-13-i
ABORTUS RINGAN
2.213.069
767
W-4-13-ii
ABORTUS SEDANG
3.026.561
768
W-4-13-iii
ABORTUS BERAT
3.746.623
769
W-4-14-i
2.937.010
770
W-4-14-ii
3.492.957
771
W-4-14-iii
4.461.826
Deskripsi (INA-CBG)
Tarif
INA-CBG
36.343.084
11.613.086
15.861.274
16.141.658
- 1101 No
Kode INACBG
772
W-4-15-i
2.264.661
773
W-4-15-ii
2.518.735
774
W-4-15-iii
3.487.427
775
W-4-16-i
3.026.561
776
W-4-16-ii
4.035.414
777
W-4-16-iii
5.501.739
778
W-4-17-i
2.218.145
779
W-4-17-ii
4.035.414
780
W-4-17-iii
7.634.202
781
Z-4-10-i
REHABILITASI RINGAN
6.924.293
782
Z-4-10-ii
REHABILITASI SEDANG
9.191.000
783
Z-4-10-iii
REHABILITASI BERAT
784
Z-4-11-i
5.423.546
785
Z-4-11-ii
6.528.751
786
Z-4-11-iii
787
Z-4-12-i
3.026.561
788
Z-4-12-ii
6.053.122
789
Z-4-12-iii
7.061.975
Deskripsi (INA-CBG)
Tarif
INA-CBG
13.056.692
11.511.634
No
Kode INACBG
B-2-10-0
1.868.808
B-2-11-0
2.424.136
B-2-12-0
4.508.001
B-2-13-0
3.725.426
B-2-14-0
3.112.272
B-3-10-0
1.091.176
B-3-11-0
2.433.180
B-3-12-0
C-3-10-0
1.363.761
10
C-3-11-0
2.156.840
11
C-3-12-0
488.951
12
C-3-13-0
474.805
13
C-3-14-0
4.042.024
14
C-3-15-0
3.704.676
15
C-3-16-0
840.131
16
C-3-17-0
557.318
17
C-3-18-0
247.091
18
C-3-19-0
349.437
19
C-3-20-0
20
C-3-21-0
21
C-3-22-0
22
C-3-23-0
23
D-2-10-0
2.402.642
24
D-2-11-0
PROSEDUR LIMPA
3.008.519
25
D-2-21-0
2.523.295
26
D-2-22-0
553.787
27
D-3-10-0
401.122
28
D-3-11-0
29
E-2-10-0
617.767
30
E-2-21-0
447.860
31
E-2-22-0

THYROGLOSSAL
447.860
32
E-3-10-0
520.832
33
F-3-10-0
TERAPI SHOCK
726.544
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
499.939
6.959.045
398.770
1.750.812
283.593
1.041.428
- 1103 No
Kode INACBG
34
F-5-10-0
890.252
35
F-5-11-0
TERAPI KELOMPOK
587.039
36
F-5-12-0
751.216
37
F-5-13-0
636.230
38
F-5-14-0
426.825
39
F-5-15-0
400.417
40
F-5-16-0
417.073
41
G-2-10-0
PROSEDUR KRANIOTOMI
351.207
42
G-2-11-0
3.044.414
43
G-2-12-0
4.412.106
44
G-2-13-0
1.082.388
45
G-2-21-0
1.974.093
46
G-2-22-0
1.791.657
47
G-2-31-0
2.956.391
48
G-2-32-0
1.515.444
49
G-3-10-0
601.489
50
G-3-11-0
801.068
51
G-3-12-0
1.312.564
52
G-3-13-0
1.312.714
53
H-2-21-0
1.722.742
54
H-2-22-0
447.860
55
H-2-23-0
447.860
56
H-2-31-0
57
H-2-32-0
296.991
58
H-2-33-0
447.860
59
H-2-34-0
1.280.185
60
H-2-35-0
421.850
61
H-2-36-0
2.277.047
62
H-2-37-0
2.424.017
63
H-3-10-0
843.381
64
H-3-11-0
443.525
65
H-3-12-0
463.063
66
H-3-13-0
449.606
67
I-2-11-0
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
2.853.578
5.184.913
- 1104 No
Kode INACBG
68
I-2-12-0
3.645.560
69
I-2-13-0
4.633.287
70
I-2-14-0
8.199.931
71
I-2-15-0
72
I-2-16-0

PENGGANTIAN ALAT
5.179.294
73
I-2-17-0
1.707.465
74
I-2-21-0
3.997.679
75
I-2-22-0
3.764.515
76
I-2-23-0
77
I-2-31-0
5.991.635
78
I-2-32-0
7.834.943
79
I-2-41-0
5.253.425
80
I-2-42-0

PERKUTAN LAIN
6.107.976
81
I-3-10-0
PROSEDUR RESUSITASI
775.353
82
I-3-11-0
409.230
83
I-3-12-0
84
I-3-13-0
781.122
85
I-3-14-0
500.673
86
I-3-15-0
443.525
87
J-2-10-0
88
J-2-21-0
89
J-2-22-0
2.230.720
90
J-2-31-0
2.893.443
91
J-2-32-0
2.153.202
92
J-3-10-0
447.860
93
J-3-11-0
94
J-3-12-0
488.951
95
J-3-13-0
719.614
96
J-3-14-0
763.949
97
J-3-15-0
669.922
98
J-3-16-0
763.949
99
J-3-17-0
447.860
100
K-2-10-0
1.289.094
101
K-2-11-0
2.752.742
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
493.128
770.397
2.378.289
2.746.021
442.658
1.265.573
- 1105 No
Kode INACBG
102
K-2-12-0
2.113.085
103
K-2-13-0
3.439.160
104
K-2-14-0
447.860
105
K-2-21-0
447.860
106
K-2-22-0
5.756.068
107
K-2-31-0
1.935.473
108
K-2-32-0
109
K-2-41-0
110
K-2-42-0
111
K-2-51-0
112
K-2-52-0
770.397
113
K-2-53-0
447.860
114
K-3-10-0
852.247
115
K-3-11-0
512.367
116
K-3-12-0
519.605
117
K-3-13-0
447.860
118
K-3-14-0
1.200.275
119
K-3-15-0
579.629
120
K-3-16-0
768.046
121
L-2-21-0
2.640.569
122
L-2-22-0
1.692.586
123
L-2-31-0
763.949
124
L-2-32-0
770.397
125
L-2-41-0
126
L-2-42-0
127
L-2-51-0
3.453.733
128
L-2-52-0
2.642.220
129
L-2-53-0
447.860
130
L-3-10-0
609.128
131
L-3-11-0
591.506
132
L-3-12-0
450.488
133
M-2-10-0
3.533.420
134
M-2-21-0
3.164.422
135
M-2-22-0
770.397
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
447.860
2.131.964
609.128
1.412.768
2.306.862
517.392
- 1106 No
Kode INACBG
136
M-2-31-0
PROSEDUR BUNION
137
M-2-32-0
609.128
138
M-2-41-0
609.128
139
M-2-42-0
209.922
140
M-2-51-0
447.860
141
M-2-52-0
447.860
142
M-2-61-0
PROSEDUR ARTROSKOPI
143
M-2-62-0
144
M-2-63-0
2.207.072
145
M-2-64-0
3.009.990
146
M-2-65-0
447.860
147
M-2-71-0
2.222.164
148
M-2-72-0
2.144.483
149
M-2-81-0
3.197.880
150
M-2-82-0
2.323.055
151
M-2-83-0
447.860
152
M-2-84-0
447.860
153
M-3-10-0
154
M-3-11-0
155
M-3-12-0
156
M-3-13-0
522.534
157
M-3-14-0
893.099
158
M-3-15-0
393.465
159
M-3-16-0
447.860
160
M-3-17-0
488.951
161
N-2-11-0
5.916.670
162
N-2-12-0
3.422.735
163
N-2-21-0
3.404.694
164
N-2-22-0
770.397
165
N-2-23-0
770.397
166
N-2-24-0
2.489.663
167
N-2-31-0
2.095.893
168
N-2-32-0
770.397
169
N-2-41-0
770.397
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
1.922.069
2.195.196
447.860
1.278.279
708.728
1.602.734
- 1107 No
Kode INACBG
170
N-2-42-0
171
N-3-10-0
770.397
172
N-3-11-0
892.615
173
N-3-12-0
689.762
174
N-3-13-0
770.397
175
N-3-14-0
662.884
176
N-3-15-0
PROSEDUR DIALISIS
177
O-7-10-0
178
O-7-11-0
179
O-7-12-0
180
O-7-13-0
316.289
181
P-9-10-0

AKUT LAIN
421.850
182
P-9-11-0
421.850
183
P-9-12-0
421.850
184
P-9-13-0
421.850
185
P-9-14-0
421.850
186
P-9-15-0
268.896
187
P-9-16-0
421.850
188
P-9-17-0
420.036
189
Q-5-10-0
549.805
190
Q-5-11-0
412.064
191
Q-5-12-0
GIGI
363.182
192
Q-5-13-0
MEDICAL CHECK-UP
276.003
193
Q-5-14-0
303.693
194
Q-5-15-0
208.850
195
Q-5-16-0
VAKSINASI
236.048
196
Q-5-17-0
PASANG INFUS
204.176
197
Q-5-18-0
384.322
198
Q-5-19-0
429.649
199
Q-5-20-0
ABORSI MENGANCAM
287.980
200
Q-5-21-0
ABORSI
284.058
201
Q-5-22-0
303.693
202
Q-5-23-0
371.801
203
Q-5-24-0
253.934
DESKRIPSI (INA-CBG)

KURETASE
Tarif
INA-CBG
1.302.888
1.699.803
283.794
1.562.927
569.114
- 1108 No
Kode INACBG
204
Q-5-25-0
396.006
205
Q-5-26-0
BRONKIAL AKUT
560.519
206
Q-5-27-0
398.892
207
Q-5-28-0
323.691
208
Q-5-29-0
916.422
209
Q-5-30-0
210
Q-5-31-0
FRAKTUR
378.891
211
Q-5-32-0
SALURAN KEMIH AKUT
438.842
212
Q-5-33-0
HEMATOLOGI AKUT
459.466
213
Q-5-34-0
INFEKSI VIRUS HIV
652.703
214
Q-5-35-0
INFEKSI AKUT
740.147
215
Q-5-36-0
861.950
216
Q-5-37-0
439.638
217
Q-5-38-0
PARU AKUT
586.272
218
Q-5-39-0
375.171
219
Q-5-40-0
368.103
220
Q-5-41-0
509.586
221
Q-5-42-0
399.536
222
Q-5-43-0
575.354
223
Q-5-44-0
469.569
224
T-2-10-0
243.558
225
U-2-10-0
3.250.550
226
U-2-11-0
3.863.641
227
U-2-12-0
425.101
228
U-2-13-0
557.318
229
U-2-14-0
230
U-2-15-0
588.203
231
U-2-21-0
685.165
232
U-2-22-0
1.323.794
233
U-2-23-0
1.734.598
234
U-2-24-0
1.461.889
235
U-2-25-0
557.318
236
U-2-31-0
447.860
237
U-2-32-0
557.318
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
1.062.034
1.035.245
- 1109 No
Kode INACBG
238
U-3-10-0

TENGGOROKAN
532.826
239
U-3-11-0
565.695
240
U-3-12-0
250.149
241
U-3-13-0

TENGGOROKAN
549.848
242
U-3-14-0
505.197
243
U-3-15-0
440.577
244
U-3-16-0
PROSEDUR PADA GIGI
496.891
245
V-2-10-0
246
V-2-11-0
PROSEDUR PADA PENIS
247
V-2-12-0
248
V-2-13-0
770.397
249
V-2-14-0
770.397
250
V-2-15-0
SIRKUMSISI/SUNAT
421.850
251
V-3-10-0
879.796
252
V-3-11-0
1.861.226
253
V-3-12-0
1.074.535
254
W-2-10-0
PROSEDUR ABORSI
255
W-2-11-0
1.005.550
256
W-2-12-0
1.861.226
257
W-2-13-0
258
W-2-21-0
3.741.559
259
W-2-22-0
393.465
260
W-2-23-0
1.313.012
261
W-2-31-0
4.310.218
262
W-2-32-0
3.022.952
263
W-2-33-0
1.284.794
264
W-2-34-0
265
W-3-10-0
266
W-3-11-0
848.959
267
W-3-12-0
393.465
268
Z-3-10-0
4.454.547
269
Z-3-11-0

SALURAN EMPEDU
3.404.694
270
Z-3-12-0
271
Z-3-13-0
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
4.847.742
546.702
1.744.604
393.465
298.507
436.981
1.062.033
568.502
3.469.152
- 1110 No
Kode INACBG
272
Z-3-14-0
DIAGNOSTIK TIDUR
685.959
273
Z-3-15-0
447.860
274
Z-3-16-0
275
Z-3-17-0
PENGOBATAN NUKLIR
603.491
276
Z-3-18-0
CT-SCAN KEPALA
581.452
277
Z-3-19-0
CT SCAN LAIN-LAIN
605.179
278
Z-3-20-0
411.597
279
Z-3-21-0
393.465
280
Z-3-22-0
443.596
281
Z-3-23-0
462.044
282
Z-3-24-0
907.825
283
Z-3-25-0
404.344
284
Z-3-26-0
456.988
285
Z-3-27-0
PERAWATAN LUKA
436.300
286
Z-3-28-0
IMAGING PAYUDARA
447.860
287
Z-3-29-0
IMAGING LAIN-LAIN
288
Z-3-30-0
FOTOTERAPI
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
1.437.495
1.290.813
217.841
- 1111 -
VIII. TARIF INA-CBG RUMAH SAKIT JANTUNG DAN PEMBULUH

DARAH HARAPAN KITA TAHUN 2012
a. RawatInap
No
Kode
INA-CBG
A-4-10-i
SEPTIKEMIA RINGAN
3.740.538
A-4-10-ii
SEPTIKEMIA SEDANG
6.392.915
A-4-10-iii
SEPTIKEMIA BERAT
8.335.171
A-4-11-i
10.036.906
A-4-11-ii
15.505.861
A-4-11-iii
25.364.200
A-4-12-i
DEMAM RINGAN
3.274.317
A-4-12-ii
DEMAM SEDANG
5.647.210
A-4-12-iii
DEMAM BERAT
6.462.817
10
A-4-13-i
4.092.896
11
A-4-13-ii
4.911.475
12
A-4-13-iii
5.969.317
13
A-4-14-i
3.443.850
14
A-4-14-ii
5.616.912
15
A-4-14-iii
6.268.310
16
A-4-15-i
INFEKSI HIV RINGAN
4.911.475
17
A-4-15-ii
INFEKSI HIV SEDANG
7.367.212
18
A-4-15-iii
INFEKSI HIV BERAT
12.320.688
19
B-1-01-i
54.451.357
20
B-1-01-ii
60.074.404
21
B-1-01-iii
105.382.867
22
B-1-10-i
7.059.434
23
B-1-10-ii
17.990.837
24
B-1-10-iii
37.655.606
25
B-1-11-i
5.803.228
26
B-1-11-ii
14.566.649
27
B-1-11-iii
18.262.962
28
B-1-12-i
12.378.493
29
B-1-12-ii
26.530.139
Deskripsi (INA-CBG)
Tarif
INA-CBG
- 1112 No
Kode
INA-CBG
30
B-1-12-iii
31
B-1-13-i
8.111.351
32
B-1-13-ii
13.212.214
33
B-1-13-iii
19.478.511
34
B-1-14-i
11.014.644
35
B-1-14-ii
12.250.507
36
B-1-14-iii
19.164.462
37
B-4-10-i
3.081.730
38
B-4-10-ii
4.464.326
39
B-4-10-iii
7.524.587
40
B-4-11-i
7.440.451
41
B-4-11-ii
11.311.343
42
B-4-11-iii
12.182.710
43
B-4-12-i
6.528.486
44
B-4-12-ii
9.255.787
45
B-4-12-iii
46
B-4-13-i
4.911.475
47
B-4-13-ii
6.392.103
48
B-4-13-iii
49
B-4-14-i
5.653.647
50
B-4-14-ii
6.353.141
51
B-4-14-iii
8.081.800
52
C-4-10-i
5.751.208
53
C-4-10-ii
11.173.994
54
C-4-10-iii
LEUKEMIA AKUT BERAT
16.490.078
55
C-4-11-i
5.785.696
56
C-4-11-ii
6.629.361
57
C-4-11-iii
58
C-4-12-i
RADIOTERAPI RINGAN
3.274.317
59
C-4-12-ii
RADIOTERAPI SEDANG
10.840.585
60
C-4-12-iii
RADIOTERAPI BERAT
22.008.560
61
C-4-13-i
KEMOTERAPI RINGAN
3.274.317
62
C-4-13-ii
KEMOTERAPI SEDANG
6.548.633
63
C-4-13-iii
KEMOTERAPI BERAT
8.568.402
Deskripsi (INA-CBG)
Tarif
INA-CBG
32.288.179
17.590.407
10.562.991
13.387.753
- 1113 No
Kode
INA-CBG
64
C-4-14-i
5.105.629
65
C-4-14-ii
7.460.672
66
C-4-14-iii
11.373.578
67
D-1-10-i
34.842.612
68
D-1-10-ii
53.067.971
69
D-1-10-iii
71.921.601
70
D-1-11-i
8.611.687
71
D-1-11-ii
22.053.951
72
D-1-11-iii
30.902.663
73
D-1-20-i
8.821.580
74
D-1-20-ii
21.719.508
75
D-1-20-iii
38.594.414
76
D-4-10-i
3.392.164
77
D-4-10-ii
6.350.715
78
D-4-10-iii
8.185.792
79
D-4-11-i
4.092.896
80
D-4-11-ii
8.285.890
81
D-4-11-iii
82
D-4-12-i
4.198.530
83
D-4-12-ii
5.823.774
84
D-4-12-iii
8.942.408
85
D-4-13-i
3.274.317
86
D-4-13-ii
4.911.475
87
D-4-13-iii
6.067.634
88
D-4-14-i
4.092.896
89
D-4-14-ii
9.210.965
90
D-4-14-iii
91
E-1-01-i
9.438.133
92
E-1-01-ii
12.363.056
93
E-1-01-iii
24.505.634
94
E-1-10-i
7.997.592
95
E-1-10-ii
9.707.199
96
E-1-10-iii
20.459.918
97
E-1-20-i
11.136.629
Deskripsi (INA-CBG)
Tarif
INA-CBG
12.551.970
10.987.407
- 1114 No
Kode
INA-CBG
98
E-1-20-ii
14.915.716
99
E-1-20-iii
33.049.011
100
E-4-10-i
4.569.671
101
E-4-10-ii
6.999.593
102
E-4-10-iii
103
E-4-11-i
4.199.179
104
E-4-11-ii
7.944.126
105
E-4-11-iii
106
E-4-12-i
4.502.185
107
E-4-12-ii
7.367.212
108
E-4-12-iii
109
E-4-13-i
5.292.409
110
E-4-13-ii
9.087.103
111
E-4-13-iii
112
F-4-10-i
SCHIZOFRENIA RINGAN
6.470.971
113
F-4-10-ii
SCHIZOFRENIA SEDANG
7.186.221
114
F-4-10-iii
SCHIZOFRENIA BERAT
115
F-4-11-i
5.964.668
116
F-4-11-ii
6.949.404
117
F-4-11-iii
DEPRESI MAYOR BERAT
8.911.676
118
F-4-12-i
2.912.755
119
F-4-12-ii
3.861.512
120
F-4-12-iii
7.606.644
121
F-4-13-i
4.820.358
122
F-4-13-ii
6.383.393
123
F-4-13-iii
8.230.570
124
F-4-14-i
DEPRESI RINGAN
3.374.251
125
F-4-14-ii
DEPRESI SEDANG
4.328.161
126
F-4-14-iii
DEPRESI BERAT
5.823.733
127
F-4-15-i
4.011.792
128
F-4-15-ii
5.647.773
129
F-4-15-iii
7.053.913
130
F-4-16-i
8.640.615
131
F-4-16-ii
10.044.498
Deskripsi (INA-CBG)
Tarif
INA-CBG
11.872.558
13.100.229
11.836.302
15.722.984
10.639.359
- 1115 No
Kode
INA-CBG
132
F-4-16-iii
133
F-4-17-i
1.659.083
134
F-4-17-ii
4.862.614
135
F-4-17-iii
5.188.052
136
F-4-18-i
7.489.394
137
F-4-18-ii
8.240.448
138
F-4-18-iii
139
F-4-19-i
5.743.658
140
F-4-19-ii
7.354.902
141
F-4-19-iii
9.156.952
142
G-1-01-i
15.185.534
143
G-1-01-ii
25.703.346
144
G-1-01-iii
49.758.806
145
G-1-10-i
9.112.818
146
G-1-10-ii
12.865.034
147
G-1-10-iii
15.247.813
148
G-1-11-i
10.511.908
149
G-1-11-ii
21.586.995
150
G-1-11-iii
44.107.902
151
G-1-12-i
8.175.167
152
G-1-12-ii
18.716.231
153
G-1-12-iii
29.347.272
154
G-1-13-i
1.792.999
155
G-1-13-ii
4.815.797
156
G-1-13-iii
10.866.466
157
G-1-20-i
10.301.406
158
G-1-20-ii
13.917.538
159
G-1-20-iii
34.075.453
160
G-1-30-i
13.138.516
161
G-1-30-ii
34.292.787
162
G-1-30-iii
44.145.415
163
G-4-10-i
4.911.475
164
G-4-10-ii
6.004.552
165
G-4-10-iii
Deskripsi (INA-CBG)
Tarif
INA-CBG
13.407.729
12.703.369
10.526.439
- 1116 No
Kode
INA-CBG
166
G-4-11-i
9.744.403
167
G-4-11-ii
11.303.507
168
G-4-11-iii
16.565.485
169
G-4-12-i
7.287.956
170
G-4-12-ii
9.182.824
171
G-4-12-iii
172
G-4-13-i
4.054.970
173
G-4-13-ii
5.730.054
174
G-4-13-iii
6.773.738
175
G-4-14-i
7.415.935
176
G-4-14-ii
7.692.239
177
G-4-14-iii
Deskripsi (INA-CBG)
Tarif
INA-CBG
13.336.959
15.276.826
178
G-4-15-i
179
G-4-15-ii
180
G-4-15-iii
181
G-4-16-i
4.098.196
182
G-4-16-ii
6.120.963
183
G-4-16-iii
184
G-4-17-i
7.033.458
185
G-4-17-ii
8.728.831
186
G-4-17-iii
187
G-4-18-i
4.911.475
188
G-4-18-ii
8.468.117
189
G-4-18-iii
8.971.108
190
G-4-19-i
191
G-4-19-ii
192
G-4-19-iii
193
G-4-20-i
2.888.691
194
G-4-20-ii
4.068.342
195
G-4-20-iii
6.937.475
196
G-4-21-i
3.992.130
197
G-4-21-ii
5.549.061
198
G-4-21-iii
9.740.797
199
G-4-22-i
3.274.317

RINGAN
SEDANG
BERAT
4.911.475
6.226.644
9.425.476
11.108.454
14.629.593
4.919.001
8.713.199
12.395.882
- 1117 No
Kode
INA-CBG
200
G-4-22-ii
4.092.896
201
G-4-22-iii
4.695.621
202
G-4-23-i
3.600.361
203
G-4-23-ii
4.092.896
204
G-4-23-iii
5.850.505
205
G-4-24-i
3.274.317
206
G-4-24-ii
4.369.558
207
G-4-24-iii
TRAUMA KEPALA BERAT
8.600.778
208
G-4-25-i
GEGAR OTAK RINGAN
3.274.317
209
G-4-25-ii
GEGAR OTAK SEDANG
4.092.896
210
G-4-25-iii
GEGAR OTAK BERAT
5.110.758
211
G-4-26-i
5.933.521
212
G-4-26-ii
6.728.810
213
G-4-26-iii
214
H-1-20-i
5.659.447
215
H-1-20-ii
10.320.642
216
H-1-20-iii
14.035.429
217
H-1-30-i
5.541.138
218
H-1-30-ii
6.316.897
219
H-1-30-iii
220
H-4-10-i
5.019.343
221
H-4-10-ii
8.185.792
222
H-4-10-iii
223
H-4-11-i
4.021.307
224
H-4-11-ii
4.438.750
225
H-4-11-iii
5.889.278
226
H-4-12-i
5.579.402
227
H-4-12-ii
7.557.665
228
H-4-12-iii
12.609.449
229
I-1-01-i
70.639.459
230
I-1-01-ii
72.193.895
231
I-1-01-iii
113.956.678
232
I-1-02-i
39.190.365
233
I-1-02-ii
50.555.570
Deskripsi (INA-CBG)
Tarif
INA-CBG
10.937.872
10.539.514
13.345.258
- 1118 No
Kode
INA-CBG
234
I-1-02-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
Tarif
INA-CBG
62.312.680
235
I-1-03-i
236
I-1-03-ii
237
I-1-03-iii
61.214.159
238
I-1-04-i
35.405.578
239
I-1-04-ii
45.479.094
240
I-1-04-iii
96.951.985
241
I-1-05-i
242
I-1-05-ii
243
I-1-05-iii
244
I-1-06-i
29.311.526
245
I-1-06-ii
36.213.195
246
I-1-06-iii
67.346.653
247
I-1-07-i
42.441.746
248
I-1-07-ii
52.448.704
249
I-1-07-iii
97.397.101
250
I-1-11-i
251
I-1-11-ii
252
I-1-11-iii
253
I-1-12-i
25.397.270
254
I-1-12-ii
36.383.932
255
I-1-12-iii
44.875.690
256
I-1-13-i
11.484.418
257
I-1-13-ii
14.842.784
258
I-1-13-iii
28.122.173
259
I-1-14-i
40.343.022
260
I-1-14-ii
50.140.614
261
I-1-14-iii
65.701.494
262
I-1-15-i
10.293.415
263
I-1-15-ii
12.189.070
264
I-1-15-iii
66.158.123
265
I-1-16-i
266
I-1-16-ii

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT

33.462.496
41.633.186
51.869.600
62.243.520
93.882.886
7.354.907
8.177.921
10.882.321
17.289.867
44.953.654
- 1119 No
Kode
INA-CBG
267
I-1-16-iii

268
I-1-17-i
6.667.756
269
I-1-17-ii
13.811.340
270
I-1-17-iii
21.936.918
271
I-1-20-i
24.204.654
272
I-1-20-ii
25.900.408
273
I-1-20-iii
49.350.800
Deskripsi (INA-CBG)

RINGAN
SEDANG
Tarif
INA-CBG
51.852.936
274
I-1-30-i
66.337.646
275
I-1-30-ii
276
I-1-30-iii
89.314.327
277
I-1-40-i
17.966.018
278
I-1-40-ii
19.928.725
279
I-1-40-iii
23.314.356
280
I-4-10-i
9.224.942
281
I-4-10-ii
14.566.348
282
I-4-10-iii
21.013.228
283
I-4-11-i
10.552.448
284
I-4-11-ii
12.278.687
285
I-4-11-iii
19.922.138
286
I-4-12-i
9.580.874
287
I-4-12-ii
13.671.880
288
I-4-12-iii
16.585.913
289
I-4-13-i
290
I-4-13-ii
12.503.137
291
I-4-13-iii
21.283.058
292
I-4-14-i
5.352.298
293
I-4-14-ii
6.262.980
294
I-4-14-iii
9.705.535
295
I-4-15-i
6.548.633
296
I-4-15-ii
11.272.890
297
I-4-15-iii
12.848.382
298
I-4-16-i
4.911.475
299
I-4-16-ii
7.959.809
300
I-4-16-iii
79.505.211
8.606.258
10.027.946
- 1120 No
Kode
INA-CBG
301
I-4-17-i
HIPERTENSI RINGAN
5.285.708
302
I-4-17-ii
HIPERTENSI SEDANG
7.210.667
303
I-4-17-iii
HIPERTENSI BERAT
8.427.822
304
I-4-18-i
7.784.329
305
I-4-18-ii
11.925.071
306
I-4-18-iii
16.076.907
307
I-4-19-i
6.092.258
308
I-4-19-ii
9.889.897
309
I-4-19-iii
310
I-4-20-i
7.393.818
311
I-4-20-ii
8.518.230
312
I-4-20-iii
313
I-4-21-i
9.832.581
314
I-4-21-ii
12.265.506
315
I-4-21-iii
16.732.752
316
I-4-22-i
5.320.765
317
I-4-22-ii
6.131.113
318
I-4-22-iii
8.945.128
319
I-4-23-i
320
I-4-23-ii
321
I-4-23-iii
322
I-4-24-i
5.780.994
323
I-4-24-ii
14.433.543
324
I-4-24-iii
18.248.608
325
J-1-01-i
46.575.694
326
J-1-01-ii
49.756.645
327
J-1-01-iii
85.009.520
328
J-1-02-i
23.808.571
329
J-1-02-ii
25.505.323
330
J-1-02-iii
37.689.600
331
J-1-10-i
9.290.449
332
J-1-10-ii
22.439.810
333
J-1-10-iii
37.955.240
334
J-1-20-i
Deskripsi (INA-CBG)

Tarif
INA-CBG
11.328.563
11.305.109
4.030.779
4.948.868
9.669.637
8.029.920
- 1121 No
Kode
INA-CBG
335
J-1-20-ii
11.678.885
336
J-1-20-iii
17.141.171
337
J-1-30-i
5.415.019
338
J-1-30-ii
23.237.948
339
J-1-30-iii
66.513.748
340
J-4-10-i
5.197.300
341
J-4-10-ii
7.431.515
342
J-4-10-iii
343
J-4-11-i
3.942.737
344
J-4-11-ii
5.488.200
345
J-4-11-iii
7.864.730
346
J-4-12-i
EMBOLI PARU RINGAN
5.014.190
347
J-4-12-ii
EMBOLI PARU SEDANG
6.493.205
348
J-4-12-iii
EMBOLI PARU BERAT
8.671.019
349
J-4-13-i
9.287.671
350
J-4-13-ii
13.652.877
351
J-4-13-iii
22.197.534
352
J-4-14-i
TUMOR PARU RINGAN
6.329.255
353
J-4-14-ii
TUMOR PARU SEDANG
10.602.368
354
J-4-14-iii
TUMOR PARU BERAT
12.605.676
355
J-4-15-i
5.541.021
356
J-4-15-ii
7.802.087
357
J-4-15-iii
9.804.322
358
J-4-16-i
4.092.896
359
J-4-16-ii
6.513.961
360
J-4-16-iii
361
J-4-17-i
4.536.400
362
J-4-17-ii
6.157.211
363
J-4-17-iii
9.875.633
364
J-4-18-i
3.274.317
365
J-4-18-ii
4.703.963
366
J-4-18-iii
4.919.177
367
J-4-19-i
5.748.744
368
J-4-19-ii
7.802.030
Deskripsi (INA-CBG)
Tarif
INA-CBG
11.242.773
10.673.367
- 1122 No
Kode
INA-CBG
369
J-4-19-iii
370
J-4-20-i
6.345.892
371
J-4-20-ii
8.404.869
372
J-4-20-iii
373
J-4-21-i
3.532.268
374
J-4-21-ii
8.078.337
375
J-4-21-iii
376
K-1-10-i
8.821.580
377
K-1-10-ii
14.803.857
378
K-1-10-iii
17.337.866
379
K-1-11-i
9.121.062
380
K-1-11-ii
11.974.853
381
K-1-11-iii
30.389.820
382
K-1-12-i
4.906.433
383
K-1-12-ii
6.394.600
384
K-1-12-iii
385
K-1-13-i
5.573.035
386
K-1-13-ii
9.734.492
387
K-1-13-iii
388
K-1-14-i
9.006.355
389
K-1-14-ii
10.578.984
390
K-1-14-iii
26.048.527
391
K-1-20-i
17.474.971
392
K-1-20-ii
24.390.450
393
K-1-20-iii
52.099.154
394
K-1-30-i
11.502.895
395
K-1-30-ii
17.643.161
396
K-1-30-iii
33.040.521
397
K-1-40-i
11.556.047
398
K-1-40-ii
12.716.282
399
K-1-40-iii
21.088.729
400
K-1-50-i
8.814.476
401
K-1-50-ii
11.415.162
402
K-1-50-iii
PROSEDUR ANAL BERAT
16.206.494
Deskripsi (INA-CBG)
Tarif
INA-CBG
11.152.563
16.753.154
11.522.351
12.720.204
10.410.688
- 1123 No
Kode
INA-CBG
403
K-4-10-i
6.676.331
404
K-4-10-ii
7.988.622
405
K-4-10-iii
406
K-4-11-i
3.298.226
407
K-4-11-ii
5.352.840
408
K-4-11-iii
8.977.764
409
K-4-12-i
3.367.503
410
K-4-12-ii
5.882.270
411
K-4-12-iii
Deskripsi (INA-CBG)

(RINGAN)
(SEDANG)
(BERAT)
Tarif
INA-CBG
27.510.441
14.117.029
412
K-4-13-i
4.911.475
413
K-4-13-ii
414
K-4-13-iii
415
K-4-14-i
4.092.896
416
K-4-14-ii
5.539.307
417
K-4-14-iii
8.991.162
418
K-4-15-i
4.092.896
419
K-4-15-ii
7.695.760
420
K-4-15-iii
421
K-4-16-i
4.092.896
422
K-4-16-ii
5.364.319
423
K-4-16-iii
7.208.986
424
K-4-17-i
3.274.317
425
K-4-17-ii
5.744.599
426
K-4-17-iii
7.645.475
427
K-4-18-i
3.924.480
428
K-4-18-ii
6.112.328
429
K-4-18-iii
7.107.225
430
L-1-20-i
18.740.193
431
L-1-20-ii
20.771.144
432
L-1-20-iii
64.217.361
433
L-1-30-i
15.437.766
434
L-1-30-ii
26.471.396
435
L-1-30-iii
27.919.064
436
L-1-40-i
6.361.569
10.404.744
10.949.682
7.378.913
- 1124 No
Kode
INA-CBG
437
L-1-40-ii
16.607.719
438
L-1-40-iii
25.309.842
439
L-1-50-i
11.026.976
440
L-1-50-ii
19.848.556
441
L-1-50-iii
23.999.712
442
L-4-10-i
4.911.475
443
L-4-10-ii
6.772.453
444
L-4-10-iii
445
L-4-11-i
5.585.958
446
L-4-11-ii
7.652.665
447
L-4-11-iii
448
L-4-12-i
5.514.325
449
L-4-12-ii
8.665.406
450
L-4-12-iii
451
L-4-13-i
3.706.990
452
L-4-13-ii
4.274.378
453
L-4-13-iii
6.411.900
454
L-4-14-i
3.378.189
455
L-4-14-ii
5.020.860
456
L-4-14-iii
9.234.067
Deskripsi (INA-CBG)

(RINGAN)
(SEDANG)
(BERAT)
Tarif
INA-CBG
13.938.450
20.753.070
14.033.315
457
M-1-01-i
458
M-1-01-ii
459
M-1-01-iii
460
M-1-02-i
13.595.585
461
M-1-02-ii
22.321.365
462
M-1-02-iii
40.422.969
463
M-1-03-i
464
M-1-03-ii
465
M-1-03-iii
466
M-1-04-i
467
M-1-04-ii
468
M-1-04-iii
469
M-1-05-i

RINGAN
SEDANG
BERAT
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
15.963.569
17.817.926
25.029.358
28.670.136
33.552.444
39.035.063
8.968.600
11.497.652
14.387.144
13.971.356
- 1125 No
Kode
INA-CBG
470
M-1-05-ii
471
M-1-05-iii
472
M-1-07-i
473
M-1-07-ii
474
M-1-07-iii
475
M-1-10-i
9.638.717
476
M-1-10-ii
13.019.442
477
M-1-10-iii
23.020.478
478
M-1-20-i
9.535.181
479
M-1-20-ii
10.802.076
480
M-1-20-iii
26.456.070
481
M-1-30-i
5.703.464
482
M-1-30-ii
11.784.807
483
M-1-30-iii
PROSEDUR KAKI BERAT
17.580.448
484
M-1-40-i
5.632.173
485
M-1-40-ii
9.270.300
486
M-1-40-iii
487
M-1-50-i
7.632.244
488
M-1-50-ii
15.363.887
489
M-1-50-iii
17.643.161
Deskripsi (INA-CBG)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
Tarif
INA-CBG
16.147.144
27.502.984
12.825.502
17.182.164
35.001.698
15.437.766
490
M-1-60-i
5.759.936
491
M-1-60-ii
492
M-1-60-iii
493
M-1-70-i
7.715.998
494
M-1-70-ii
15.744.458
495
M-1-70-iii
25.381.968
496
M-1-80-i
6.217.006
497
M-1-80-ii
9.398.843
498
M-1-80-iii
499
M-4-10-i
3.348.129
500
M-4-10-ii
6.007.336
501
M-4-10-iii
FRAKTUR FEMUR BERAT
502
M-4-11-i
5.210.821
503
M-4-11-ii
11.954.399
11.531.430
20.068.767
21.638.570
12.756.261
- 1126 No
Kode
INA-CBG
504
M-4-11-iii
21.218.778
505
M-4-12-i
3.274.317
506
M-4-12-ii
5.957.615
507
M-4-12-iii
Deskripsi (INA-CBG)

RINGAN
SEDANG
Tarif
INA-CBG
13.097.267
508
M-4-13-i
509
M-4-13-ii
510
M-4-13-iii
511
M-4-14-i
6.548.633
512
M-4-14-ii
10.223.351
513
M-4-14-iii
OSTEOMIELITIS BERAT
14.842.364
514
M-4-15-i
4.912.912
515
M-4-15-ii
6.550.964
516
M-4-15-iii
517
M-4-16-i
4.908.166
518
M-4-16-ii
7.172.365
519
M-4-16-iii
520
M-4-17-i
4.205.024
521
M-4-17-ii
5.730.054
522
M-4-17-iii
8.002.325
523
M-4-18-i
5.768.914
524
M-4-18-ii
7.104.264
525
M-4-18-iii
9.783.741

ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
7.268.610
8.185.792
21.622.293
13.915.846
14.642.269
526
M-4-19-i
4.289.266
527
M-4-19-ii
528
M-4-19-iii
529
M-4-20-i
530
M-4-20-ii
531
M-4-20-iii
532
M-4-21-i
533
M-4-21-ii
534
M-4-21-iii
535
N-1-01-i
8.859.415
536
N-1-01-ii
11.982.159
7.224.497
12.255.658
3.274.317
4.911.475
5.443.072
3.274.317
5.139.171
11.869.398
- 1127 No
Kode
INA-CBG
537
N-1-01-iii
25.405.741
538
N-1-11-i
14.697.020
539
N-1-11-ii
19.877.387
540
N-1-11-iii
35.286.322
541
N-1-12-i
542
N-1-12-ii

SEDANG
18.508.692
543
N-1-12-iii
33.733.243
544
N-1-20-i
10.771.575
545
N-1-20-ii
21.356.203
546
N-1-20-iii
24.429.561
547
N-1-30-i
12.814.689
548
N-1-30-ii
19.473.519
549
N-1-30-iii
22.417.231
550
N-1-40-i
11.547.289
551
N-1-40-ii
15.652.763
552
N-1-40-iii
18.204.615
553
N-4-10-i
4.503.856
554
N-4-10-ii
6.590.199
555
N-4-10-iii
556
N-4-11-i
3.768.999
557
N-4-11-ii
6.369.518
558
N-4-11-iii
7.288.808
559
N-4-12-i
3.644.447
560
N-4-12-ii
5.122.172
561
N-4-12-iii
8.154.663
562
N-4-13-i
BATU URIN RINGAN
5.194.514
563
N-4-13-ii
BATU URIN SEDANG
6.262.630
564
N-4-13-iii
BATU URIN BERAT
565
N-4-14-i
566
N-4-14-ii
567
N-4-14-iii
568
N-4-15-i
5.059.646
569
N-4-15-ii
6.943.408
570
N-4-15-iii
7.923.681
Deskripsi (INA-CBG)

Tarif
INA-CBG
6.616.185
12.987.163
15.423.140
2.836.165
4.367.337
7.082.429
- 1128 No
Kode
INA-CBG
571
N-4-16-i
5.081.494
572
N-4-16-ii
6.557.544
573
N-4-16-iii
574
O-6-10-i
6.320.438
575
O-6-10-ii
7.016.650
576
O-6-10-iii
8.646.890
Deskripsi (INA-CBG)

RINGAN
SEDANG
BERAT
Tarif
INA-CBG
13.770.802
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
2.079.667
584
O-6-13-ii
3.653.128
585
O-6-13-iii
4.543.148
586
P-8-01-i
587
P-8-01-ii
588
P-8-01-iii
589
P-8-02-i
590
P-8-02-ii
591
P-8-02-iii
592
P-8-03-i
593
P-8-03-ii
594
P-8-03-iii
595
P-8-04-i
596
P-8-04-ii
597
P-8-04-iii
598
P-8-05-i
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
3.990.177
6.501.168
11.017.462
4.412.822
5.299.788
6.658.424
82.269.951
101.796.195
119.480.197
119.859.054
137.490.672
157.092.924
5.513.488
7.718.883
13.342.095
59.209.343
76.840.961
110.170.597
32.196.121
45.633.661
67.235.074
4.508.641
13.232.371
- 1129 No
Kode
INA-CBG
603
P-8-06-iii
604
P-8-07-i
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
4.603.597
614
P-8-11-ii
25.021.841
615
P-8-11-iii
25.546.052
616
P-8-12-i
5.544.763
617
P-8-12-ii
8.621.143
618
P-8-12-iii
619
P-8-13-i
2.865.832
620
P-8-13-ii
5.303.200
621
P-8-13-iii
7.931.503
Deskripsi (INA-CBG)
BERAT
RINGAN
SEDANG
BERAT
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
AKUT LAIN RINGAN
AKUT LAIN SEDANG
AKUT LAIN BERAT

RINGAN
SEDANG
BERAT
Tarif
INA-CBG
24.259.346
8.556.101
21.641.889
28.670.136
6.726.359
9.549.012
13.480.273
4.173.025
6.045.234
11.868.576
10.171.126
622
P-8-14-i
5.236.174
623
P-8-14-ii
624
P-8-14-iii
625
P-8-15-i
3.937.766
626
P-8-15-ii
7.870.559
627
P-8-15-iii
9.245.189
628
P-8-16-i
3.564.609
629
P-8-16-ii
5.056.550
630
P-8-16-iii
6.563.650
631
P-8-17-i
2.348.363
632
P-8-17-ii
7.814.654
633
P-8-17-iii
634
S-4-10-i
3.274.317
635
S-4-10-ii
4.092.896
10.690.784
11.727.751
15.773.382
- 1130 No
Kode
INA-CBG
636
S-4-10-iii
5.320.062
637
S-4-11-i
2.046.448
638
S-4-11-ii
3.274.317
639
S-4-11-iii
5.039.092
640
S-4-12-i
2.455.737
641
S-4-12-ii
3.274.317
642
S-4-12-iii
6.395.000
643
S-4-13-i
3.506.692
644
S-4-13-ii
5.788.257
645
S-4-13-iii
646
S-4-14-i
1.994.981
647
S-4-14-ii
4.238.009
648
S-4-14-iii
8.036.774
649
S-4-15-i
1.508.822
650
S-4-15-ii
2.847.662
651
S-4-15-iii
3.688.384
652
S-4-16-i
LUKA BAKAR RINGAN
5.730.054
653
S-4-16-ii
LUKA BAKAR SEDANG
9.731.321
654
S-4-16-iii
LUKA BAKAR BERAT
655
S-4-17-i
3.674.033
656
S-4-17-ii
4.278.790
657
S-4-17-iii
6.674.274
658
T-1-10-i
3.792.616
659
T-1-10-ii
5.093.226
660
T-1-10-iii
9.266.238
Deskripsi (INA-CBG)

RINGAN
SEDANG
Tarif
INA-CBG
11.785.628
17.376.785
661
T-4-10-i
1.379.646
662
T-4-10-ii
663
T-4-10-iii
664
T-4-11-i
665
T-4-11-ii
666
T-4-11-iii
4.158.718
667
T-4-12-i
2.865.027
668
T-4-12-ii
4.330.331
669
T-4-12-iii
6.736.439
2.629.300
3.822.288
1.640.654
2.581.923
- 1131 No
Kode
INA-CBG
670
U-1-10-i
3.049.559
671
U-1-10-ii
6.222.812
672
U-1-10-iii
26.871.360
673
U-1-11-i
13.232.371
674
U-1-11-ii
17.643.161
675
U-1-11-iii
35.644.038
676
U-1-12-i
9.723.796
677
U-1-12-ii
19.848.556
678
U-1-12-iii
25.773.726
679
U-1-13-i
8.821.580
680
U-1-13-ii
11.026.976
681
U-1-13-iii
19.192.454
682
U-1-14-i
5.853.041
683
U-1-14-ii
7.182.858
684
U-1-14-iii
8.511.889
685
U-1-15-i
3.437.714
686
U-1-15-ii
4.884.752
687
U-1-15-iii
9.625.599
688
U-1-20-i
8.891.869
689
U-1-20-ii
15.635.538
690
U-1-20-iii
32.472.103
691
U-1-30-i
7.627.673
692
U-1-30-ii
10.297.358
693
U-1-30-iii
17.643.161
694
U-4-10-i
7.100.089
695
U-4-10-ii
17.798.433
696
U-4-10-iii
25.964.038
697
U-4-11-i
3.294.998
698
U-4-11-ii
4.911.475
699
U-4-11-iii
8.167.912
700
U-4-12-i
3.274.317
701
U-4-12-ii
4.589.989
702
U-4-12-iii
7.297.874
U-4-13-i

RINGAN
3.274.317
703
Deskripsi (INA-CBG)
Tarif
INA-CBG
- 1132 No
Kode
INA-CBG
704
U-4-13-ii

SEDANG
3.739.689
705
U-4-13-iii
5.105.906
706
U-4-14-i
4.092.896
707
U-4-14-ii
4.911.475
708
U-4-14-iii
8.227.573
709
U-4-15-i
3.274.317
710
U-4-15-ii
4.152.294
711
U-4-15-iii
5.731.165
712
V-1-10-i
9.726.098
713
V-1-10-ii
11.039.976
714
V-1-10-iii
20.951.253
715
V-1-11-i
11.026.976
716
V-1-11-ii
12.306.290
717
V-1-11-iii
18.223.731
718
V-1-12-i
7.161.320
719
V-1-12-ii
24.453.905
720
V-1-12-iii
27.501.623
721
V-1-13-i
10.854.239
722
V-1-13-ii
20.626.169
723
V-1-13-iii
26.464.741
724
V-1-14-i
13.084.911
725
V-1-14-ii
19.030.883
726
V-1-14-iii
25.869.716
727
V-1-15-i
6.168.807
728
V-1-15-ii
10.324.992
729
V-1-15-iii
17.178.599
730
V-4-10-i
9.933.337
731
V-4-10-ii
12.830.091
732
V-4-10-iii
24.520.556
733
V-4-11-i
5.051.474
734
V-4-11-ii
7.381.010
735
V-4-11-iii
736
W-1-01-i
737
W-1-01-ii
Deskripsi (INA-CBG)

RINGAN
SEDANG
Tarif
INA-CBG
12.178.178
14.853.807
17.890.706
- 1133 No
Kode
INA-CBG
738
W-1-01-iii

BERAT
739
W-1-10-i
4.136.767
740
W-1-10-ii
7.719.887
741
W-1-10-iii
742
W-1-11-i
4.296.725
743
W-1-11-ii
8.286.779
744
W-1-11-iii
745
W-1-12-i
3.904.221
746
W-1-12-ii
4.439.024
747
W-1-12-iii
6.818.901
748
W-1-13-i
3.864.465
749
W-1-13-ii
4.195.695
750
W-1-13-iii
5.635.593
751
W-1-20-i
12.661.603
752
W-1-20-ii
17.643.161
753
W-1-20-iii
19.848.556
754
W-1-30-i
6.911.966
755
W-1-30-ii
11.024.943
756
W-1-30-iii
29.318.035
757
W-4-10-i
5.154.595
758
W-4-10-ii
6.967.012
759
W-4-10-iii
760
W-4-11-i
4.092.896
761
W-4-11-ii
6.548.633
762
W-4-11-iii
7.958.530
763
W-4-12-i
3.274.317
764
W-4-12-ii
5.002.900
765
W-4-12-iii
6.035.777
766
W-4-13-i
ABORTUS RINGAN
1.795.674
767
W-4-13-ii
ABORTUS SEDANG
2.455.737
768
W-4-13-iii
ABORTUS BERAT
3.274.317
769
W-4-14-i
2.455.737
770
W-4-14-ii
3.274.317
771
W-4-14-iii
3.974.328
Deskripsi (INA-CBG)
Tarif
INA-CBG
36.236.609
12.627.285
13.232.371
13.097.267
- 1134 No
Kode
INA-CBG
772
W-4-15-i
2.455.737
773
W-4-15-ii
2.639.307
774
W-4-15-iii
3.339.191
775
W-4-16-i
2.470.519
776
W-4-16-ii
3.914.063
777
W-4-16-iii
4.988.389
778
W-4-17-i
2.411.861
779
W-4-17-ii
3.274.317
780
W-4-17-iii
6.194.356
781
Z-4-10-i
REHABILITASI RINGAN
5.618.340
782
Z-4-10-ii
REHABILITASI SEDANG
7.457.535
783
Z-4-10-iii
REHABILITASI BERAT
784
Z-4-11-i
5.897.198
785
Z-4-11-ii
7.098.923
786
Z-4-11-iii
787
Z-4-12-i
2.455.737
788
Z-4-12-ii
6.016.595
789
Z-4-12-iii
7.646.139
Deskripsi (INA-CBG)
Tarif
INA-CBG
10.594.140
11.098.189
No
Kode
INA-CBG
B-2-10-0
2.135.968
B-2-11-0
2.770.685
B-2-12-0
5.152.454
B-2-13-0
4.258.003
B-2-14-0
3.557.195
B-3-10-0
1.247.168
B-3-11-0
2.781.021
B-3-12-0
C-3-10-0
1.558.721
10
C-3-11-0
2.465.177
11
C-3-12-0
558.851
12
C-3-13-0
542.682
13
C-3-14-0
4.619.861
14
C-3-15-0
4.234.287
15
C-3-16-0
960.234
16
C-3-17-0
636.991
17
C-3-18-0
282.414
18
C-3-19-0
399.391
19
C-3-20-0
20
C-3-21-0
21
C-3-22-0
22
C-3-23-0
23
D-2-10-0
2.746.118
24
D-2-11-0
PROSEDUR LIMPA
3.438.609
25
D-2-21-0
2.884.019
26
D-2-22-0
632.956
27
D-3-10-0
458.465
28
D-3-11-0
29
E-2-10-0
706.082
30
E-2-21-0
511.885
31
E-2-22-0

THYROGLOSSAL
511.885
32
E-3-10-0
595.289
33
F-3-10-0
TERAPI SHOCK
830.409
Deskripsi (INA-CBG)
Tarif
INA-CBG
571.409
7.953.893
455.777
2.001.104
324.135
1.190.308
- 1136 No
Kode
INA-CBG
34
F-5-10-0
35
F-5-11-0
TERAPI KELOMPOK
670.961
36
F-5-12-0
858.608
37
F-5-13-0
727.184
38
F-5-14-0
487.843
39
F-5-15-0
457.660
40
F-5-16-0
476.696
41
G-2-10-0
PROSEDUR KRANIOTOMI
401.415
42
G-2-11-0
3.479.636
43
G-2-12-0
5.042.849
44
G-2-13-0
1.237.123
45
G-2-21-0
2.256.305
46
G-2-22-0
2.047.788
47
G-2-31-0
3.379.029
48
G-2-32-0
1.732.088
49
G-3-10-0
687.477
50
G-3-11-0
915.587
51
G-3-12-0
1.500.205
52
G-3-13-0
1.500.376
53
H-2-21-0
1.969.021
54
H-2-22-0
511.885
55
H-2-23-0
511.885
56
H-2-31-0
57
H-2-32-0
339.448
58
H-2-33-0
511.885
59
H-2-34-0
1.463.197
60
H-2-35-0
482.157
61
H-2-36-0
2.602.568
62
H-2-37-0
2.770.549
63
H-3-10-0
963.948
64
H-3-11-0
506.930
65
H-3-12-0
529.261
66
H-3-13-0
513.881
67
I-2-11-0
Deskripsi (INA-CBG)
Tarif
INA-CBG
1.017.520
3.261.519
5.926.136
- 1137 No
Kode
INA-CBG
68
I-2-12-0
4.166.720
69
I-2-13-0
5.295.650
70
I-2-14-0
9.372.173
71
I-2-15-0
72
I-2-16-0

PENGGANTIAN ALAT
5.919.713
73
I-2-17-0
1.951.559
74
I-2-21-0
4.569.177
75
I-2-22-0
4.302.680
76
I-2-23-0
77
I-2-31-0
6.848.184
78
I-2-32-0
8.955.007
79
I-2-41-0
6.004.442
80
I-2-42-0

PERKUTAN LAIN
6.981.157
81
I-3-10-0
PROSEDUR RESUSITASI
886.196
82
I-3-11-0
467.732
83
I-3-12-0
84
I-3-13-0
892.789
85
I-3-14-0
572.247
86
I-3-15-0
506.930
87
J-2-10-0
88
J-2-21-0
89
J-2-22-0
2.549.618
90
J-2-31-0
3.307.083
91
J-2-32-0
2.461.018
92
J-3-10-0
511.885
93
J-3-11-0
94
J-3-12-0
558.851
95
J-3-13-0
822.488
96
J-3-14-0
873.161
97
J-3-15-0
765.692
98
J-3-16-0
873.161
99
J-3-17-0
511.885
100
K-2-10-0
1.473.380
101
K-2-11-0
3.146.268
Deskripsi (INA-CBG)
Tarif
INA-CBG
563.624
880.531
2.718.283
3.138.585
505.939
1.446.496
- 1138 No
Kode
INA-CBG
102
K-2-12-0
2.415.166
103
K-2-13-0
3.930.814
104
K-2-14-0
511.885
105
K-2-21-0
511.885
106
K-2-22-0
6.578.941
107
K-2-31-0
2.212.163
108
K-2-32-0
109
K-2-41-0
110
K-2-42-0
111
K-2-51-0
112
K-2-52-0
880.531
113
K-2-53-0
511.885
114
K-3-10-0
974.083
115
K-3-11-0
585.614
116
K-3-12-0
593.886
117
K-3-13-0
511.885
118
K-3-14-0
1.371.863
119
K-3-15-0
662.492
120
K-3-16-0
877.844
121
L-2-21-0
3.018.059
122
L-2-22-0
1.934.554
123
L-2-31-0
873.161
124
L-2-32-0
880.531
125
L-2-41-0
126
L-2-42-0
127
L-2-51-0
3.947.470
128
L-2-52-0
3.019.945
129
L-2-53-0
511.885
130
L-3-10-0
696.208
131
L-3-11-0
676.066
132
L-3-12-0
514.889
133
M-2-10-0
4.038.549
134
M-2-21-0
3.616.800
135
M-2-22-0
880.531
Deskripsi (INA-CBG)
Tarif
INA-CBG
511.885
2.436.744
696.208
1.614.734
2.636.645
591.357
- 1139 No
Kode
INA-CBG
136
M-2-31-0
PROSEDUR BUNION
137
M-2-32-0
696.208
138
M-2-41-0
696.208
139
M-2-42-0
239.932
140
M-2-51-0
511.885
141
M-2-52-0
511.885
142
M-2-61-0
PROSEDUR ARTROSKOPI
143
M-2-62-0
144
M-2-63-0
2.522.589
145
M-2-64-0
3.440.290
146
M-2-65-0
511.885
147
M-2-71-0
2.539.838
148
M-2-72-0
2.451.052
149
M-2-81-0
3.655.041
150
M-2-82-0
2.655.153
151
M-2-83-0
511.885
152
M-2-84-0
511.885
153
M-3-10-0
154
M-3-11-0
155
M-3-12-0
156
M-3-13-0
157
M-3-14-0
158
M-3-15-0
449.714
159
M-3-16-0
511.885
160
M-3-17-0
558.851
161
N-2-11-0
6.762.503
162
N-2-12-0
3.912.041
163
N-2-21-0
3.891.420
164
N-2-22-0
880.531
165
N-2-23-0
880.531
166
N-2-24-0
2.845.579
167
N-2-31-0
2.395.517
168
N-2-32-0
880.531
169
N-2-41-0
880.531
Deskripsi (INA-CBG)
Tarif
INA-CBG
2.196.843
2.509.016
511.885
1.461.018
810.046
1.831.856
597.235
1.020.775
- 1140 No
Kode
INA-CBG
170
N-2-42-0
171
N-3-10-0
172
N-3-11-0
173
N-3-12-0
788.369
174
N-3-13-0
880.531
175
N-3-14-0
757.649
176
N-3-15-0
PROSEDUR DIALISIS
177
O-7-10-0
178
O-7-11-0
179
O-7-12-0
180
O-7-13-0
361.505
181
P-9-10-0

AKUT LAIN
482.157
182
P-9-11-0
482.157
183
P-9-12-0
482.157
184
P-9-13-0
482.157
185
P-9-14-0
482.157
186
P-9-15-0
307.337
187
P-9-16-0
482.157
188
P-9-17-0
480.083
189
Q-5-10-0
628.404
190
Q-5-11-0
470.972
191
Q-5-12-0
GIGI
415.102
192
Q-5-13-0
MEDICAL CHECK-UP
315.459
193
Q-5-14-0
347.108
194
Q-5-15-0
238.706
195
Q-5-16-0
VAKSINASI
269.793
196
Q-5-17-0
PASANG INFUS
233.364
197
Q-5-18-0
439.264
198
Q-5-19-0
491.071
199
Q-5-20-0
ABORSI MENGANCAM
329.149
200
Q-5-21-0
ABORSI
324.666
201
Q-5-22-0
347.108
202
Q-5-23-0
424.952
203
Q-5-24-0
290.236
Deskripsi (INA-CBG)

KURETASE
Tarif
INA-CBG
1.489.146
880.531
1.020.221
1.942.802
324.364
1.786.359
650.474
- 1141 No
Kode
INA-CBG
204
Q-5-25-0
452.618
205
Q-5-26-0
BRONKIAL AKUT
640.649
206
Q-5-27-0
455.917
207
Q-5-28-0
369.965
208
Q-5-29-0
1.047.431
209
Q-5-30-0
1.213.860
210
Q-5-31-0
FRAKTUR
433.057
211
Q-5-32-0
SALURAN KEMIH AKUT
501.577
212
Q-5-33-0
HEMATOLOGI AKUT
525.150
213
Q-5-34-0
INFEKSI VIRUS HIV
746.012
214
Q-5-35-0
INFEKSI AKUT
845.957
215
Q-5-36-0
985.172
216
Q-5-37-0
502.488
217
Q-5-38-0
PARU AKUT
670.084
218
Q-5-39-0
428.804
219
Q-5-40-0
420.726
220
Q-5-41-0
582.435
221
Q-5-42-0
456.652
222
Q-5-43-0
657.606
223
Q-5-44-0
536.697
224
T-2-10-0
278.376
225
U-2-10-0
3.715.241
226
U-2-11-0
4.415.977
227
U-2-12-0
485.873
228
U-2-13-0
636.991
229
U-2-14-0
230
U-2-15-0
672.291
231
U-2-21-0
783.115
232
U-2-22-0
1.513.041
233
U-2-23-0
1.982.572
234
U-2-24-0
1.670.877
235
U-2-25-0
636.991
236
U-2-31-0
511.885
237
U-2-32-0
636.991
Deskripsi (INA-CBG)
Tarif
INA-CBG
1.183.241
- 1142 No
Kode
INA-CBG
238
U-3-10-0

TENGGOROKAN
608.997
239
U-3-11-0
646.565
240
U-3-12-0
285.910
241
U-3-13-0

TENGGOROKAN
628.453
242
U-3-14-0
577.419
243
U-3-15-0
503.561
244
U-3-16-0
PROSEDUR PADA GIGI
567.925
245
V-2-10-0
246
V-2-11-0
PROSEDUR PADA PENIS
247
V-2-12-0
248
V-2-13-0
880.531
249
V-2-14-0
880.531
250
V-2-15-0
SIRKUMSISI/SUNAT
482.157
251
V-3-10-0
1.005.570
252
V-3-11-0
2.127.302
253
V-3-12-0
1.228.147
254
W-2-10-0
PROSEDUR ABORSI
255
W-2-11-0
1.149.301
256
W-2-12-0
2.127.302
257
W-2-13-0
258
W-2-21-0
4.276.443
259
W-2-22-0
449.714
260
W-2-23-0
1.500.717
261
W-2-31-0
4.926.396
262
W-2-32-0
3.455.105
263
W-2-33-0
1.468.465
264
W-2-34-0
265
W-3-10-0
266
W-3-11-0
970.324
267
W-3-12-0
449.714
268
Z-3-10-0
5.091.358
269
Z-3-11-0

SALURAN EMPEDU
3.891.420
270
Z-3-12-0
271
Z-3-13-0
Deskripsi (INA-CBG)
Tarif
INA-CBG
5.540.764
624.857
1.994.008
449.714
341.181
499.451
1.213.859
649.773
3.965.093
- 1143 No
Kode
INA-CBG
272
Z-3-14-0
DIAGNOSTIK TIDUR
784.022
273
Z-3-15-0
511.885
274
Z-3-16-0
275
Z-3-17-0
PENGOBATAN NUKLIR
689.765
276
Z-3-18-0
CT-SCAN KEPALA
664.575
277
Z-3-19-0
CT SCAN LAIN-LAIN
691.693
278
Z-3-20-0
470.438
279
Z-3-21-0
449.714
280
Z-3-22-0
507.011
281
Z-3-23-0
528.097
282
Z-3-24-0
283
Z-3-25-0
462.148
284
Z-3-26-0
522.318
285
Z-3-27-0
PERAWATAN LUKA
498.672
286
Z-3-28-0
IMAGING PAYUDARA
511.885
287
Z-3-29-0
IMAGING LAIN-LAIN
288
Z-3-30-0
FOTOTERAPI
Deskripsi (INA-CBG)
Tarif
INA-CBG
1.642.995
1.037.605
1.475.345
248.984
- 1144 -
IX.
TARIF INA-CBG RUMAH SAKIT KANKER DHARMAIS TAHUN

2012
a. RawatInap
No
Kode
INA-CBG
A-4-10-i
SEPTIKEMIA RINGAN
3.538.118
A-4-10-ii
SEPTIKEMIA SEDANG
6.046.961
A-4-10-iii
SEPTIKEMIA BERAT
A-4-11-i
9.493.757
A-4-11-ii
14.666.757
A-4-11-iii
23.991.611
A-4-12-i
DEMAM RINGAN
4.164.010
A-4-12-ii
DEMAM SEDANG
5.341.610
A-4-12-iii
DEMAM BERAT
6.353.693
10
A-4-13-i
5.205.013
11
A-4-13-ii
5.851.752
12
A-4-13-iii
7.357.601
13
A-4-14-i
4.164.010
14
A-4-14-ii
5.312.952
15
A-4-14-iii
6.122.424
16
A-4-15-i
INFEKSI HIV RINGAN
6.246.016
17
A-4-15-ii
INFEKSI HIV SEDANG
9.369.024
18
A-4-15-iii
INFEKSI HIV BERAT
11.653.951
19
B-1-01-i
69.246.822
20
B-1-01-ii
76.397.757
21
B-1-01-iii
134.017.388
22
B-1-10-i
8.977.615
23
B-1-10-ii
22.879.288
24
B-1-10-iii
35.617.865
25
B-1-11-i
5.489.185
26
B-1-11-ii
13.778.371
27
B-1-11-iii
17.274.658
28
B-1-12-i
11.708.628
29
B-1-12-ii
25.094.455
Deskripsi (INA-CBG)
Tarif
INA-CBG
10.599.995
- 1145 No
Kode
INA-CBG
30
B-1-12-iii
31
B-1-13-i
7.672.404
32
B-1-13-ii
12.497.232
33
B-1-13-iii
18.424.427
34
B-1-14-i
10.418.584
35
B-1-14-ii
11.587.568
36
B-1-14-iii
18.127.373
37
B-4-10-i
3.257.802
38
B-4-10-ii
5.205.013
39
B-4-10-iii
7.117.392
40
B-4-11-i
7.037.809
41
B-4-11-ii
10.699.228
42
B-4-11-iii
11.523.440
43
B-4-12-i
6.175.195
44
B-4-12-ii
8.754.908
45
B-4-12-iii
46
B-4-13-i
6.246.016
47
B-4-13-ii
7.287.018
48
B-4-13-iii
49
B-4-14-i
6.246.016
50
B-4-14-ii
7.287.018
51
B-4-14-iii
9.721.616
52
C-4-10-i
5.439.980
53
C-4-10-ii
11.451.029
54
C-4-10-iii
LEUKEMIA AKUT BERAT
19.779.050
55
C-4-11-i
6.246.016
56
C-4-11-ii
8.328.021
57
C-4-11-iii
58
C-4-12-i
RADIOTERAPI RINGAN
4.164.010
59
C-4-12-ii
RADIOTERAPI SEDANG
10.253.944
60
C-4-12-iii
RADIOTERAPI BERAT
20.817.562
61
C-4-13-i
KEMOTERAPI RINGAN
4.021.014
62
C-4-13-ii
KEMOTERAPI SEDANG
7.550.236
63
C-4-13-iii
KEMOTERAPI BERAT
Deskripsi (INA-CBG)
Tarif
INA-CBG
30.540.897
19.025.272
13.161.184
13.012.533
10.425.396
- 1146 No
Kode
INA-CBG
64
C-4-14-i
5.205.013
65
C-4-14-ii
7.287.018
66
C-4-14-iii
10.758.094
67
D-1-10-i
44.310.010
68
D-1-10-ii
67.487.544
69
D-1-10-iii
91.464.063
70
D-1-11-i
8.413.928
71
D-1-11-ii
21.245.386
72
D-1-11-iii
33.655.713
73
D-1-20-i
11.218.571
74
D-1-20-ii
25.241.784
75
D-1-20-iii
40.809.704
76
D-4-10-i
3.999.788
77
D-4-10-ii
7.959.911
78
D-4-10-iii
79
D-4-11-i
5.035.512
80
D-4-11-ii
7.837.497
81
D-4-11-iii
82
D-4-12-i
5.339.350
83
D-4-12-ii
7.406.204
84
D-4-12-iii
85
D-4-13-i
4.001.972
86
D-4-13-ii
5.652.250
87
D-4-13-iii
7.287.018
88
D-4-14-i
4.487.250
89
D-4-14-ii
11.713.759
90
D-4-14-iii
13.972.894
91
E-1-01-i
8.927.386
92
E-1-01-ii
12.533.311
93
E-1-01-iii
29.634.590
94
E-1-10-i
10.170.689
95
E-1-10-ii
12.344.829
96
E-1-10-iii
26.019.265
97
E-1-20-i
10.533.968
Deskripsi (INA-CBG)
Tarif
INA-CBG
10.410.026
11.872.717
11.372.230
- 1147 No
Kode
INA-CBG
98
E-1-20-ii
14.108.548
99
E-1-20-iii
31.260.556
100
E-4-10-i
5.205.013
101
E-4-10-ii
7.287.018
102
E-4-10-iii
103
E-4-11-i
4.164.010
104
E-4-11-ii
7.514.228
105
E-4-11-iii
106
E-4-12-i
4.745.913
107
E-4-12-ii
8.244.545
108
E-4-12-iii
109
E-4-13-i
5.205.013
110
E-4-13-ii
8.595.353
111
E-4-13-iii
112
F-4-10-i
SCHIZOFRENIA RINGAN
6.120.793
113
F-4-10-ii
SCHIZOFRENIA SEDANG
6.797.337
114
F-4-10-iii
SCHIZOFRENIA BERAT
115
F-4-11-i
5.641.888
116
F-4-11-ii
6.573.336
117
F-4-11-iii
DEPRESI MAYOR BERAT
8.429.419
118
F-4-12-i
3.123.008
119
F-4-12-ii
4.459.212
120
F-4-12-iii
9.673.513
121
F-4-13-i
4.559.503
122
F-4-13-ii
6.037.954
123
F-4-13-iii
7.785.171
124
F-4-14-i
DEPRESI RINGAN
3.191.653
125
F-4-14-ii
DEPRESI SEDANG
4.093.941
126
F-4-14-iii
DEPRESI BERAT
5.508.581
127
F-4-15-i
4.164.010
128
F-4-15-ii
6.246.016
129
F-4-15-iii
8.226.386
130
F-4-16-i
8.173.026
131
F-4-16-ii
9.500.938
Deskripsi (INA-CBG)
Tarif
INA-CBG
14.149.970
13.507.733
14.606.338
14.872.131
10.063.608
- 1148 No
Kode
INA-CBG
132
F-4-16-iii
133
F-4-17-i
2.109.887
134
F-4-17-ii
6.183.878
135
F-4-17-iii
6.597.743
136
F-4-18-i
7.084.103
137
F-4-18-ii
7.794.515
138
F-4-18-iii
139
F-4-19-i
5.432.839
140
F-4-19-ii
6.956.890
141
F-4-19-iii
8.661.421
142
G-1-01-i
19.311.731
143
G-1-01-ii
32.687.431
144
G-1-01-iii
63.279.216
145
G-1-10-i
8.619.676
146
G-1-10-ii
12.168.840
147
G-1-10-iii
14.422.674
148
G-1-11-i
9.943.054
149
G-1-11-ii
20.418.810
150
G-1-11-iii
42.755.132
151
G-1-12-i
8.413.928
152
G-1-12-ii
17.703.398
153
G-1-12-iii
31.224.913
154
G-1-13-i
2.280.191
155
G-1-13-ii
6.124.340
156
G-1-13-iii
157
G-1-20-i
9.743.943
158
G-1-20-ii
13.164.387
159
G-1-20-iii
32.231.453
160
G-1-30-i
12.427.523
161
G-1-30-ii
32.437.025
162
G-1-30-iii
41.756.476
163
G-4-10-i
5.904.295
164
G-4-10-ii
7.287.018
165
G-4-10-iii
9.956.798
Deskripsi (INA-CBG)
Tarif
INA-CBG
12.682.166
12.015.924
13.819.090
- 1149 No
Kode
INA-CBG
166
G-4-11-i
9.217.082
167
G-4-11-ii
10.691.815
168
G-4-11-iii
15.669.040
169
G-4-12-i
6.893.566
170
G-4-12-ii
8.685.893
171
G-4-12-iii
172
G-4-13-i
4.164.010
173
G-4-13-ii
7.287.018
174
G-4-13-iii
8.614.290
175
G-4-14-i
7.014.620
176
G-4-14-ii
11.541.417
177
G-4-14-iii
14.450.117
Deskripsi (INA-CBG)
Tarif
INA-CBG
12.617.088
178
G-4-15-i
179
G-4-15-ii
180
G-4-15-iii
181
G-4-16-i
5.205.013
182
G-4-16-ii
7.784.144
183
G-4-16-iii
184
G-4-17-i
6.652.841
185
G-4-17-ii
8.256.469
186
G-4-17-iii
187
G-4-18-i
6.246.016
188
G-4-18-ii
8.328.021
189
G-4-18-iii
9.369.024
190
G-4-19-i
191
G-4-19-ii
192
G-4-19-iii
193
G-4-20-i
3.643.509
194
G-4-20-ii
5.173.787
195
G-4-20-iii
8.822.519
196
G-4-21-i
3.776.095
197
G-4-21-ii
5.248.772
198
G-4-21-iii
9.213.672
199
G-4-22-i
3.899.936

RINGAN
SEDANG
BERAT
6.246.016
7.918.542
11.986.556
14.126.831
13.837.909
5.205.013
10.548.659
15.735.251
- 1150 No
Kode
INA-CBG
200
G-4-22-ii
4.991.918
201
G-4-22-iii
5.849.903
202
G-4-23-i
4.164.010
203
G-4-23-ii
5.205.013
204
G-4-23-iii
7.440.198
205
G-4-24-i
4.164.010
206
G-4-24-ii
5.205.013
207
G-4-24-iii
TRAUMA KEPALA BERAT
208
G-4-25-i
GEGAR OTAK RINGAN
3.538.751
209
G-4-25-ii
GEGAR OTAK SEDANG
4.455.365
210
G-4-25-iii
GEGAR OTAK BERAT
5.904.302
211
G-4-26-i
6.246.016
212
G-4-26-ii
7.287.018
213
G-4-26-iii
214
H-1-20-i
5.353.185
215
H-1-20-ii
9.762.139
216
H-1-20-iii
217
H-1-30-i
5.241.278
218
H-1-30-ii
5.975.057
219
H-1-30-iii
9.969.166
220
H-4-10-i
6.246.016
221
H-4-10-ii
10.410.026
222
H-4-10-iii
16.971.417
223
H-4-11-i
4.164.010
224
H-4-11-ii
4.751.927
225
H-4-11-iii
6.794.811
226
H-4-12-i
5.277.472
227
H-4-12-ii
7.148.680
228
H-4-12-iii
11.927.086
229
I-1-01-i
89.833.537
230
I-1-01-ii
91.810.343
231
I-1-01-iii
144.920.866
232
I-1-02-i
49.839.129
233
I-1-02-ii
64.292.476
Deskripsi (INA-CBG)
Tarif
INA-CBG
10.937.772
13.909.898
13.275.898
- 1151 No
Kode
INA-CBG
234
I-1-02-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
Tarif
INA-CBG
79.244.215
235
I-1-03-i
236
I-1-03-ii
237
I-1-03-iii
61.702.140
238
I-1-04-i
33.489.597
239
I-1-04-ii
43.017.982
240
I-1-04-iii
91.705.406
241
I-1-05-i
242
I-1-05-ii
243
I-1-05-iii
244
I-1-06-i
27.809.840
245
I-1-06-ii
41.950.674
246
I-1-06-iii
78.724.245
247
I-1-07-i
36.572.045
248
I-1-07-ii
45.119.047
249
I-1-07-iii
49.224.587
250
I-1-11-i
251
I-1-11-ii
252
I-1-11-iii
253
I-1-12-i
23.839.463
254
I-1-12-ii
33.078.368
255
I-1-12-iii
46.136.515
256
I-1-13-i
14.023.214
257
I-1-13-ii
18.753.045
258
I-1-13-iii
26.600.335
259
I-1-14-i
51.304.986
260
I-1-14-ii
63.764.768
261
I-1-14-iii
83.553.834
262
I-1-15-i
11.218.571
263
I-1-15-ii
29.448.749
264
I-1-15-iii
51.151.383
265
I-1-16-i
266
I-1-16-ii

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT

29.957.132
42.069.641
65.963.553
79.156.264
108.918.519
6.956.895
7.735.371
10.293.422
21.987.851
57.168.413
- 1152 No
Kode
INA-CBG
267
I-1-16-iii

268
I-1-17-i
6.306.929
269
I-1-17-ii
13.063.936
270
I-1-17-iii
20.749.796
271
I-1-20-i
14.023.214
272
I-1-20-ii
20.536.830
273
I-1-20-iii
33.655.713
Deskripsi (INA-CBG)

RINGAN
SEDANG
Tarif
INA-CBG
65.942.361
274
I-1-30-i
24.945.331
275
I-1-30-ii
276
I-1-30-iii
80.412.712
277
I-1-40-i
14.023.214
278
I-1-40-ii
22.714.157
279
I-1-40-iii
34.226.035
280
I-4-10-i
8.725.732
281
I-4-10-ii
13.778.087
282
I-4-10-iii
19.876.093
283
I-4-11-i
10.346.436
284
I-4-11-ii
12.803.755
285
I-4-11-iii
23.684.281
286
I-4-12-i
9.062.403
287
I-4-12-ii
12.932.023
288
I-4-12-iii
16.111.724
289
I-4-13-i
290
I-4-13-ii
11.826.527
291
I-4-13-iii
27.066.068
292
I-4-14-i
5.062.657
293
I-4-14-ii
5.924.057
294
I-4-14-iii
9.180.318
295
I-4-15-i
8.328.021
296
I-4-15-ii
10.662.855
297
I-4-15-iii
12.153.089
298
I-4-16-i
6.246.016
299
I-4-16-ii
10.122.640
300
I-4-16-iii
12.752.729
51.891.328
8.140.529
- 1153 No
Kode
INA-CBG
301
I-4-17-i
HIPERTENSI RINGAN
5.205.013
302
I-4-17-ii
HIPERTENSI SEDANG
7.916.074
303
I-4-17-iii
HIPERTENSI BERAT
9.630.282
304
I-4-18-i
7.363.078
305
I-4-18-ii
11.279.743
306
I-4-18-iii
15.206.901
307
I-4-19-i
5.762.574
308
I-4-19-ii
10.553.507
309
I-4-19-iii
12.579.684
310
I-4-20-i
6.993.700
311
I-4-20-ii
8.057.264
312
I-4-20-iii
313
I-4-21-i
9.300.488
314
I-4-21-ii
11.601.756
315
I-4-21-iii
15.827.255
316
I-4-22-i
6.575.218
317
I-4-22-ii
7.728.757
318
I-4-22-iii
319
I-4-23-i
320
I-4-23-ii
321
I-4-23-iii
322
I-4-24-i
5.468.154
323
I-4-24-ii
13.652.469
324
I-4-24-iii
17.261.080
325
J-1-01-i
50.210.568
326
J-1-01-ii
54.690.533
327
J-1-01-iii
80.409.210
328
J-1-02-i
22.520.165
329
J-1-02-ii
24.125.097
330
J-1-02-iii
35.650.019
331
J-1-10-i
8.787.694
332
J-1-10-ii
21.225.474
333
J-1-10-iii
37.582.311
334
J-1-20-i
Deskripsi (INA-CBG)

Tarif
INA-CBG
10.693.331
11.375.688
5.126.018
6.293.569
12.297.060
7.595.379
- 1154 No
Kode
INA-CBG
335
J-1-20-ii
11.046.880
336
J-1-20-iii
16.611.095
337
J-1-30-i
5.121.984
338
J-1-30-ii
28.046.427
339
J-1-30-iii
84.586.793
340
J-4-10-i
6.609.505
341
J-4-10-ii
9.450.798
342
J-4-10-iii
343
J-4-11-i
3.729.375
344
J-4-11-ii
5.191.205
345
J-4-11-iii
7.439.129
346
J-4-12-i
EMBOLI PARU RINGAN
6.376.641
347
J-4-12-ii
EMBOLI PARU SEDANG
8.257.532
348
J-4-12-iii
EMBOLI PARU BERAT
349
J-4-13-i
8.785.067
350
J-4-13-ii
12.914.048
351
J-4-13-iii
20.996.310
352
J-4-14-i
TUMOR PARU RINGAN
6.246.016
353
J-4-14-ii
TUMOR PARU SEDANG
10.028.618
354
J-4-14-iii
TUMOR PARU BERAT
11.923.517
355
J-4-15-i
6.246.016
356
J-4-15-ii
7.379.876
357
J-4-15-iii
358
J-4-16-i
5.205.013
359
J-4-16-ii
7.287.018
360
J-4-16-iii
361
J-4-17-i
5.205.013
362
J-4-17-ii
6.246.016
363
J-4-17-iii
364
J-4-18-i
4.164.010
365
J-4-18-ii
5.725.514
366
J-4-18-iii
6.028.616
367
J-4-19-i
7.287.018
368
J-4-19-ii
8.328.021
Deskripsi (INA-CBG)
Tarif
INA-CBG
14.297.647
11.027.099
10.106.911
13.145.014
11.482.941
- 1155 No
Kode
INA-CBG
369
J-4-19-iii
370
J-4-20-i
7.287.018
371
J-4-20-ii
8.328.021
372
J-4-20-iii
373
J-4-21-i
4.164.010
374
J-4-21-ii
10.273.374
375
J-4-21-iii
14.653.191
376
K-1-10-i
11.218.571
377
K-1-10-ii
14.002.743
378
K-1-10-iii
16.399.623
379
K-1-11-i
8.627.473
380
K-1-11-ii
11.326.831
381
K-1-11-iii
28.745.268
382
K-1-12-i
4.640.920
383
K-1-12-ii
6.048.555
384
K-1-12-iii
385
K-1-13-i
5.271.449
386
K-1-13-ii
9.207.708
387
K-1-13-iii
9.847.311
388
K-1-14-i
8.518.974
389
K-1-14-ii
10.006.500
390
K-1-14-iii
24.638.905
391
K-1-20-i
16.529.309
392
K-1-20-ii
23.070.556
393
K-1-20-iii
49.279.797
394
K-1-30-i
10.880.414
395
K-1-30-ii
21.205.233
396
K-1-30-iii
31.252.526
397
K-1-40-i
10.930.689
398
K-1-40-ii
12.028.137
399
K-1-40-iii
19.947.508
400
K-1-50-i
8.337.478
401
K-1-50-ii
10.797.428
402
K-1-50-iii
PROSEDUR ANAL BERAT
15.329.476
Deskripsi (INA-CBG)
Tarif
INA-CBG
13.046.821
20.085.519
12.031.847
- 1156 No
Kode
INA-CBG
403
K-4-10-i
6.315.040
404
K-4-10-ii
8.328.021
405
K-4-10-iii
406
K-4-11-i
4.164.010
407
K-4-11-ii
6.246.016
408
K-4-11-iii
409
K-4-12-i
4.164.010
410
K-4-12-ii
5.563.950
411
K-4-12-iii
Deskripsi (INA-CBG)

(RINGAN)
(SEDANG)
(BERAT)
Tarif
INA-CBG
34.985.549
11.351.261
13.353.083
412
K-4-13-i
6.246.016
413
K-4-13-ii
414
K-4-13-iii
415
K-4-14-i
5.205.013
416
K-4-14-ii
7.044.442
417
K-4-14-iii
418
K-4-15-i
5.205.013
419
K-4-15-ii
9.786.844
420
K-4-15-iii
421
K-4-16-i
5.205.013
422
K-4-16-ii
6.246.016
423
K-4-16-iii
7.287.018
424
K-4-17-i
3.745.531
425
K-4-17-ii
5.433.729
426
K-4-17-iii
7.231.739
427
K-4-18-i
4.164.010
428
K-4-18-ii
6.246.016
429
K-4-18-iii
7.647.201
430
L-1-20-i
17.726.064
431
L-1-20-ii
19.647.108
432
L-1-20-iii
60.742.224
433
L-1-30-i
17.286.044
434
L-1-30-ii
25.038.891
435
L-1-30-iii
26.408.217
436
L-1-40-i
8.090.128
13.231.909
10.655.390
13.924.918
6.979.602
- 1157 No
Kode
INA-CBG
437
L-1-40-ii
15.708.989
438
L-1-40-iii
26.622.585
439
L-1-50-i
13.933.662
440
L-1-50-ii
24.076.487
441
L-1-50-iii
29.985.699
442
L-4-10-i
6.246.016
443
L-4-10-ii
7.287.018
444
L-4-10-iii
445
L-4-11-i
5.283.673
446
L-4-11-ii
7.238.539
447
L-4-11-iii
448
L-4-12-i
6.246.016
449
L-4-12-ii
8.196.476
450
L-4-12-iii
451
L-4-13-i
3.506.385
452
L-4-13-ii
4.164.010
453
L-4-13-iii
6.064.919
454
L-4-14-i
4.164.010
455
L-4-14-ii
6.246.016
456
L-4-14-iii
8.734.363
Deskripsi (INA-CBG)

(RINGAN)
(SEDANG)
(BERAT)
Tarif
INA-CBG
13.184.167
19.630.013
15.367.538
457
M-1-01-i
458
M-1-01-ii
459
M-1-01-iii
460
M-1-02-i
12.859.857
461
M-1-02-ii
21.113.440
462
M-1-02-iii
38.235.471
463
M-1-03-i
464
M-1-03-ii
465
M-1-03-iii
466
M-1-04-i
467
M-1-04-ii
468
M-1-04-iii
469
M-1-05-i

RINGAN
SEDANG
BERAT
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
20.301.173
22.659.394
31.830.309
34.552.636
41.502.649
43.471.962
8.483.262
10.875.454
13.608.580
13.215.293
- 1158 No
Kode
INA-CBG
470
M-1-05-ii
471
M-1-05-iii
472
M-1-07-i
473
M-1-07-ii
474
M-1-07-iii
475
M-1-10-i
9.117.116
476
M-1-10-ii
12.314.892
477
M-1-10-iii
21.774.719
478
M-1-20-i
9.019.183
479
M-1-20-ii
10.217.519
480
M-1-20-iii
25.024.394
481
M-1-30-i
5.394.820
482
M-1-30-ii
11.147.070
483
M-1-30-iii
PROSEDUR KAKI BERAT
16.629.078
484
M-1-40-i
6.094.731
485
M-1-40-ii
11.218.571
486
M-1-40-iii
19.632.499
487
M-1-50-i
7.219.224
488
M-1-50-ii
14.532.467
489
M-1-50-iii
22.437.142
Deskripsi (INA-CBG)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
Tarif
INA-CBG
15.273.338
26.014.653
16.310.433
21.850.884
44.512.322
490
M-1-60-i
5.448.236
491
M-1-60-ii
492
M-1-60-iii
493
M-1-70-i
7.298.445
494
M-1-70-ii
14.892.443
495
M-1-70-iii
24.008.417
496
M-1-80-i
5.880.572
497
M-1-80-ii
8.890.222
498
M-1-80-iii
499
M-4-10-i
4.164.010
500
M-4-10-ii
6.246.016
501
M-4-10-iii
FRAKTUR FEMUR BERAT
502
M-4-11-i
5.205.013
503
M-4-11-ii
11.307.484
10.907.404
18.982.741
20.467.594
12.065.953
- 1159 No
Kode
INA-CBG
504
M-4-11-iii
20.070.519
505
M-4-12-i
4.164.010
506
M-4-12-ii
7.576.412
507
M-4-12-iii
Deskripsi (INA-CBG)

RINGAN
SEDANG
Tarif
INA-CBG
13.571.039
508
M-4-13-i
509
M-4-13-ii
510
M-4-13-iii
511
M-4-14-i
7.827.844
512
M-4-14-ii
9.670.112
513
M-4-14-iii
OSTEOMIELITIS BERAT
514
M-4-15-i
4.647.049
515
M-4-15-ii
6.196.457
516
M-4-15-iii
517
M-4-16-i
5.205.013
518
M-4-16-ii
8.328.021
519
M-4-16-iii
520
M-4-17-i
5.205.013
521
M-4-17-ii
7.287.018
522
M-4-17-iii
523
M-4-18-i
5.456.728
524
M-4-18-ii
8.328.021
525
M-4-18-iii
9.254.292

ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
6.875.267
10.410.026
20.452.198
14.484.786
17.697.044
13.849.899
10.176.708
526
M-4-19-i
4.057.151
527
M-4-19-ii
528
M-4-19-iii
529
M-4-20-i
530
M-4-20-ii
531
M-4-20-iii
532
M-4-21-i
533
M-4-21-ii
534
M-4-21-iii
535
N-1-01-i
11.266.686
536
N-1-01-ii
15.237.938
6.833.542
13.346.412
4.164.010
6.246.016
6.922.058
4.164.010
5.205.013
11.849.222
- 1160 No
Kode
INA-CBG
537
N-1-01-iii
32.308.962
538
N-1-11-i
13.901.687
539
N-1-11-ii
18.801.718
540
N-1-11-iii
39.865.235
541
N-1-12-i
542
N-1-12-ii

SEDANG
17.507.090
543
N-1-12-iii
31.907.761
544
N-1-20-i
10.188.669
545
N-1-20-ii
20.200.508
546
N-1-20-iii
23.107.550
547
N-1-30-i
12.121.220
548
N-1-30-ii
18.419.705
549
N-1-30-iii
21.204.118
550
N-1-40-i
10.922.405
551
N-1-40-ii
14.805.710
552
N-1-40-iii
17.219.468
553
N-4-10-i
5.205.013
554
N-4-10-ii
6.246.016
555
N-4-10-iii
556
N-4-11-i
3.565.039
557
N-4-11-ii
6.246.016
558
N-4-11-iii
7.807.520
559
N-4-12-i
4.164.010
560
N-4-12-ii
6.246.016
561
N-4-12-iii
562
N-4-13-i
BATU URIN RINGAN
5.205.013
563
N-4-13-ii
BATU URIN SEDANG
6.246.016
564
N-4-13-iii
BATU URIN BERAT
565
N-4-14-i
566
N-4-14-ii
567
N-4-14-iii
568
N-4-15-i
4.785.842
569
N-4-15-ii
6.567.664
570
N-4-15-iii
7.494.890
Deskripsi (INA-CBG)

Tarif
INA-CBG
7.952.060
15.255.327
10.370.439
14.588.513
3.606.805
5.554.026
9.006.859
- 1161 No
Kode
INA-CBG
571
N-4-16-i
5.205.013
572
N-4-16-ii
8.328.021
573
N-4-16-iii
574
O-6-10-i
5.978.406
575
O-6-10-ii
6.636.942
576
O-6-10-iii
8.178.961
Deskripsi (INA-CBG)

RINGAN
SEDANG
BERAT
Tarif
INA-CBG
17.512.589
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
1.967.125
584
O-6-13-ii
3.576.503
585
O-6-13-iii
4.768.671
586
P-8-01-i
587
P-8-01-ii
588
P-8-01-iii
589
P-8-02-i
590
P-8-02-ii
591
P-8-02-iii
592
P-8-03-i
593
P-8-03-ii
594
P-8-03-iii
595
P-8-04-i
596
P-8-04-ii
597
P-8-04-iii
598
P-8-05-i
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
3.774.247
6.149.356
10.421.250
4.174.021
5.012.989
6.298.102
104.624.255
129.456.150
151.945.229
113.372.854
130.050.334
148.591.805
7.011.607
9.816.250
15.462.820
56.005.216
72.682.695
104.208.691
30.453.821
43.164.185
63.596.632
5.609.285
12.623.759
- 1162 No
Kode
INA-CBG
603
P-8-06-iii
604
P-8-07-i
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
5.146.757
614
P-8-11-ii
23.667.778
615
P-8-11-iii
24.163.622
616
P-8-12-i
5.244.707
617
P-8-12-ii
8.154.608
618
P-8-12-iii
9.620.713
619
P-8-13-i
2.927.241
620
P-8-13-ii
5.016.216
621
P-8-13-iii
7.502.288
Deskripsi (INA-CBG)
BERAT
RINGAN
SEDANG
BERAT
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
AKUT LAIN RINGAN
AKUT LAIN SEDANG
AKUT LAIN BERAT

RINGAN
SEDANG
BERAT
Tarif
INA-CBG
23.481.633
9.816.250
27.522.401
36.460.355
6.362.360
9.032.265
12.750.785
3.947.201
5.718.095
11.226.305
622
P-8-14-i
4.952.817
623
P-8-14-ii
624
P-8-14-iii
625
P-8-15-i
3.724.673
626
P-8-15-ii
7.444.641
627
P-8-15-iii
8.744.884
628
P-8-16-i
3.371.709
629
P-8-16-ii
4.782.913
630
P-8-16-iii
6.208.457
631
P-8-17-i
2.488.097
632
P-8-17-ii
7.391.763
633
P-8-17-iii
634
S-4-10-i
4.164.010
635
S-4-10-ii
4.664.899
10.112.250
11.093.101
14.919.801
- 1163 No
Kode
INA-CBG
636
S-4-10-iii
6.411.782
637
S-4-11-i
2.415.865
638
S-4-11-ii
3.542.723
639
S-4-11-iii
6.054.898
640
S-4-12-i
3.123.008
641
S-4-12-ii
4.164.010
642
S-4-12-iii
8.132.642
643
S-4-13-i
4.164.010
644
S-4-13-ii
7.361.037
645
S-4-13-iii
646
S-4-14-i
2.537.055
647
S-4-14-ii
5.389.556
648
S-4-14-iii
649
S-4-15-i
1.918.798
650
S-4-15-ii
3.621.426
651
S-4-15-iii
4.690.588
652
S-4-16-i
LUKA BAKAR RINGAN
7.287.018
653
S-4-16-ii
LUKA BAKAR SEDANG
9.204.709
654
S-4-16-iii
LUKA BAKAR BERAT
655
S-4-17-i
3.475.212
656
S-4-17-ii
5.205.013
657
S-4-17-iii
8.487.801
658
T-1-10-i
3.587.378
659
T-1-10-ii
4.817.605
660
T-1-10-iii
8.764.794
Deskripsi (INA-CBG)

RINGAN
SEDANG
Tarif
INA-CBG
14.988.007
10.220.518
16.436.436
661
T-4-10-i
1.754.522
662
T-4-10-ii
663
T-4-10-iii
664
T-4-11-i
665
T-4-11-ii
666
T-4-11-iii
3.933.668
667
T-4-12-i
3.643.509
668
T-4-12-ii
5.506.964
669
T-4-12-iii
8.566.856
3.343.730
4.860.876
1.551.870
2.442.202
- 1164 No
Kode
INA-CBG
670
U-1-10-i
3.878.182
671
U-1-10-ii
7.913.668
672
U-1-10-iii
34.172.817
673
U-1-11-i
16.827.856
674
U-1-11-ii
22.437.142
675
U-1-11-iii
33.715.153
676
U-1-12-i
9.197.590
677
U-1-12-ii
25.241.784
678
U-1-12-iii
32.776.935
679
U-1-13-i
10.556.129
680
U-1-13-ii
11.320.781
681
U-1-13-iii
22.944.419
682
U-1-14-i
5.536.302
683
U-1-14-ii
6.794.156
684
U-1-14-iii
8.051.266
685
U-1-15-i
3.251.681
686
U-1-15-ii
4.620.412
687
U-1-15-iii
9.104.708
688
U-1-20-i
8.410.684
689
U-1-20-ii
14.971.017
690
U-1-20-iii
38.938.032
691
U-1-30-i
7.214.900
692
U-1-30-ii
9.740.115
693
U-1-30-iii
694
U-4-10-i
6.715.866
695
U-4-10-ii
16.835.267
696
U-4-10-iii
24.558.988
697
U-4-11-i
4.164.010
698
U-4-11-ii
6.129.487
699
U-4-11-iii
7.725.904
700
U-4-12-i
3.737.237
701
U-4-12-ii
4.341.601
702
U-4-12-iii
6.902.948
U-4-13-i

RINGAN
3.658.787
703
Deskripsi (INA-CBG)
Tarif
INA-CBG
19.093.425
- 1165 No
Kode
INA-CBG
704
U-4-13-ii

SEDANG
4.321.248
705
U-4-13-iii
5.205.013
706
U-4-14-i
5.205.013
707
U-4-14-ii
6.246.016
708
U-4-14-iii
709
U-4-15-i
4.164.010
710
U-4-15-ii
5.205.013
711
U-4-15-iii
7.288.431
712
V-1-10-i
12.172.783
713
V-1-10-ii
14.023.214
714
V-1-10-iii
25.655.375
715
V-1-11-i
12.832.764
716
V-1-11-ii
14.653.880
717
V-1-11-iii
23.077.416
718
V-1-12-i
6.773.783
719
V-1-12-ii
25.887.148
720
V-1-12-iii
30.225.604
721
V-1-13-i
10.266.860
722
V-1-13-ii
19.509.979
723
V-1-13-iii
33.345.803
724
V-1-14-i
12.376.818
725
V-1-14-ii
18.001.022
726
V-1-14-iii
24.469.771
727
V-1-15-i
5.834.981
728
V-1-15-ii
11.114.503
729
V-1-15-iii
20.870.679
730
V-4-10-i
9.395.792
731
V-4-10-ii
12.135.788
732
V-4-10-iii
23.193.620
733
V-4-11-i
5.205.013
734
V-4-11-ii
7.287.018
735
V-4-11-iii
736
W-1-01-i
737
W-1-01-ii
Deskripsi (INA-CBG)

RINGAN
SEDANG
Tarif
INA-CBG
10.463.160
11.519.153
14.049.990
16.922.546
- 1166 No
Kode
INA-CBG
738
W-1-01-iii

BERAT
739
W-1-10-i
3.912.905
740
W-1-10-ii
7.302.123
741
W-1-10-iii
742
W-1-11-i
4.064.207
743
W-1-11-ii
7.838.338
744
W-1-11-iii
745
W-1-12-i
3.692.943
746
W-1-12-ii
4.198.806
747
W-1-12-iii
6.449.895
748
W-1-13-i
4.914.513
749
W-1-13-ii
5.335.745
750
W-1-13-iii
7.166.890
751
W-1-20-i
11.976.417
752
W-1-20-ii
16.846.628
753
W-1-20-iii
21.282.040
754
W-1-30-i
6.537.923
755
W-1-30-ii
10.428.325
756
W-1-30-iii
27.731.483
757
W-4-10-i
4.875.653
758
W-4-10-ii
7.287.018
759
W-4-10-iii
760
W-4-11-i
5.205.013
761
W-4-11-ii
8.328.021
762
W-4-11-iii
763
W-4-12-i
4.164.010
764
W-4-12-ii
5.725.514
765
W-4-12-iii
6.246.016
766
W-4-13-i
ABORTUS RINGAN
2.283.592
767
W-4-13-ii
ABORTUS SEDANG
3.123.008
768
W-4-13-iii
ABORTUS BERAT
3.853.369
769
W-4-14-i
3.020.689
770
W-4-14-ii
3.592.476
771
W-4-14-iii
4.588.949
Deskripsi (INA-CBG)
Tarif
INA-CBG
37.378.542
11.943.957
16.313.181
16.656.042
10.121.014
- 1167 No
Kode
INA-CBG
772
W-4-15-i
2.329.184
773
W-4-15-ii
2.590.496
774
W-4-15-iii
3.586.788
775
W-4-16-i
3.123.008
776
W-4-16-ii
4.164.010
777
W-4-16-iii
5.677.062
778
W-4-17-i
2.281.343
779
W-4-17-ii
4.164.010
780
W-4-17-iii
7.877.480
781
Z-4-10-i
REHABILITASI RINGAN
7.144.949
782
Z-4-10-ii
REHABILITASI SEDANG
9.483.888
783
Z-4-10-iii
REHABILITASI BERAT
784
Z-4-11-i
5.578.070
785
Z-4-11-ii
6.714.763
786
Z-4-11-iii
787
Z-4-12-i
3.123.008
788
Z-4-12-ii
6.246.016
789
Z-4-12-iii
7.287.018
Deskripsi (INA-CBG)
Tarif
INA-CBG
13.472.768
11.878.474
b. RawatJalan
- 1168 -
No
Kode
INA-CBG
B-2-10-0
1.513.744
B-2-11-0
1.963.563
B-2-12-0
3.651.505
B-2-13-0
3.017.614
B-2-14-0
2.520.957
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
1.104.654
10
C-3-11-0
1.747.052
11
C-3-12-0
396.053
12
C-3-13-0
384.595
13
C-3-14-0
3.274.061
14
C-3-15-0
3.000.807
15
C-3-16-0
680.511
16
C-3-17-0
451.431
17
C-3-18-0
200.145
18
C-3-19-0
283.046
19
C-3-20-0
20
C-3-21-0
21
C-3-22-0
22
C-3-23-0
23
D-2-10-0
1.946.153
24
D-2-11-0
PROSEDUR LIMPA
2.436.916
25
D-2-21-0
2.043.882
26
D-2-22-0
448.571
27
D-3-10-0
324.911
28
D-3-11-0
843.562
29
E-2-10-0
500.395
30
E-2-21-0
362.769
31
E-2-22-0

THYROGLOSSAL
362.769
32
E-3-10-0
421.877
Deskripsi (INA-CBG)
Tarif
INA-CBG
883.859
1.970.889
404.953
5.636.864
323.006
1.418.167
229.712
- 1169 No
Kode
INA-CBG
33
F-3-10-0
TERAPI SHOCK
588.505
34
F-5-10-0
721.109
35
F-5-11-0
TERAPI KELOMPOK
475.505
36
F-5-12-0
608.489
37
F-5-13-0
515.350
38
F-5-14-0
345.731
39
F-5-15-0
324.340
40
F-5-16-0
337.831
41
G-2-10-0
PROSEDUR KRANIOTOMI
284.480
42
G-2-11-0
2.465.992
43
G-2-12-0
3.573.829
44
G-2-13-0
45
G-2-21-0
1.599.026
46
G-2-22-0
1.451.252
47
G-2-31-0
2.394.692
48
G-2-32-0
1.227.517
49
G-3-10-0
487.210
50
G-3-11-0
648.869
51
G-3-12-0
1.063.184
52
G-3-13-0
1.063.305
53
H-2-21-0
1.395.430
54
H-2-22-0
362.769
55
H-2-23-0
362.769
56
H-2-31-0
57
H-2-32-0
240.564
58
H-2-33-0
362.769
59
H-2-34-0
1.036.957
60
H-2-35-0
341.701
61
H-2-36-0
1.844.420
62
H-2-37-0
1.963.467
63
H-3-10-0
683.143
64
H-3-11-0
359.258
65
H-3-12-0
375.083
66
H-3-13-0
364.183
Deskripsi (INA-CBG)
Tarif
INA-CBG
876.740
2.311.414
- 1170 No
Kode
INA-CBG
67
I-2-11-0
4.199.807
68
I-2-12-0
2.952.923
69
I-2-13-0
3.752.987
70
I-2-14-0
6.641.988
71
I-2-15-0
72
I-2-16-0

PENGGANTIAN ALAT
4.195.256
73
I-2-17-0
1.383.055
74
I-2-21-0
3.238.141
75
I-2-22-0
3.049.277
76
I-2-23-0
77
I-2-31-0
4.853.256
78
I-2-32-0
6.346.345
79
I-2-41-0
4.255.302
80
I-2-42-0

PERKUTAN LAIN
4.947.493
81
I-3-10-0
PROSEDUR RESUSITASI
628.040
82
I-3-11-0
331.478
83
I-3-12-0
84
I-3-13-0
632.713
85
I-3-14-0
405.547
86
I-3-15-0
359.258
87
J-2-10-0
88
J-2-21-0
89
J-2-22-0
1.806.895
90
J-2-31-0
2.343.704
91
J-2-32-0
1.744.105
92
J-3-10-0
362.769
93
J-3-11-0
94
J-3-12-0
396.053
95
J-3-13-0
582.891
96
J-3-14-0
618.803
97
J-3-15-0
542.640
98
J-3-16-0
618.803
99
J-3-17-0
362.769
100
K-2-10-0
Deskripsi (INA-CBG)
Tarif
INA-CBG
399.436
624.025
1.926.426
2.224.291
358.555
1.025.121
1.044.173
- 1171 No
Kode
INA-CBG
101
K-2-11-0
2.229.736
102
K-2-12-0
1.711.610
103
K-2-13-0
2.785.738
104
K-2-14-0
362.769
105
K-2-21-0
362.769
106
K-2-22-0
4.662.445
107
K-2-31-0
1.567.743
108
K-2-32-0
109
K-2-41-0
110
K-2-42-0
111
K-2-51-0
112
K-2-52-0
624.025
113
K-2-53-0
362.769
114
K-3-10-0
690.325
115
K-3-11-0
415.020
116
K-3-12-0
420.883
117
K-3-13-0
362.769
118
K-3-14-0
972.229
119
K-3-15-0
469.503
120
K-3-16-0
622.121
121
L-2-21-0
2.138.875
122
L-2-22-0
1.371.004
123
L-2-31-0
618.803
124
L-2-32-0
624.025
125
L-2-41-0
126
L-2-42-0
127
L-2-51-0
2.797.542
128
L-2-52-0
2.140.212
129
L-2-53-0
362.769
130
L-3-10-0
493.397
131
L-3-11-0
479.123
132
L-3-12-0
364.898
133
M-2-10-0
2.862.089
134
M-2-21-0
2.563.199
Deskripsi (INA-CBG)
Tarif
INA-CBG
362.769
1.726.902
493.397
1.144.349
1.868.570
419.090
- 1172 No
Kode
INA-CBG
135
M-2-22-0
136
M-2-31-0
PROSEDUR BUNION
137
M-2-32-0
493.397
138
M-2-41-0
493.397
139
M-2-42-0
170.038
140
M-2-51-0
362.769
141
M-2-52-0
362.769
142
M-2-61-0
PROSEDUR ARTROSKOPI
143
M-2-62-0
144
M-2-63-0
1.787.740
145
M-2-64-0
2.438.108
146
M-2-65-0
362.769
147
M-2-71-0
1.799.964
148
M-2-72-0
1.737.042
149
M-2-81-0
2.590.300
150
M-2-82-0
1.881.687
151
M-2-83-0
362.769
152
M-2-84-0
362.769
153
M-3-10-0
154
M-3-11-0
155
M-3-12-0
156
M-3-13-0
423.256
157
M-3-14-0
723.415
158
M-3-15-0
318.709
159
M-3-16-0
362.769
160
M-3-17-0
396.053
161
N-2-11-0
4.792.534
162
N-2-12-0
2.772.434
163
N-2-21-0
2.757.820
164
N-2-22-0
624.025
165
N-2-23-0
624.025
166
N-2-24-0
2.016.640
167
N-2-31-0
1.697.684
168
N-2-32-0
624.025
Deskripsi (INA-CBG)
Tarif
INA-CBG
624.025
1.556.886
1.778.121
362.769
1.035.413
574.073
1.298.223
- 1173 No
Kode
INA-CBG
169
N-2-41-0
624.025
170
N-2-42-0
1.055.346
171
N-3-10-0
624.025
172
N-3-11-0
723.023
173
N-3-12-0
558.711
174
N-3-13-0
624.025
175
N-3-14-0
536.940
176
N-3-15-0
PROSEDUR DIALISIS
177
O-7-10-0
Deskripsi (INA-CBG)

KURETASE
Tarif
INA-CBG
1.376.849
229.874
178
O-7-11-0
1.265.979
179
O-7-12-0
180
O-7-13-0
256.196
181
P-9-10-0

AKUT LAIN
341.701
182
P-9-11-0
341.701
183
P-9-12-0
341.701
184
P-9-13-0
341.701
185
P-9-14-0
341.701
186
P-9-15-0
217.807
187
P-9-16-0
341.701
188
P-9-17-0
340.231
189
Q-5-10-0
445.345
190
Q-5-11-0
333.774
191
Q-5-12-0
GIGI
294.180
192
Q-5-13-0
MEDICAL CHECK-UP
223.564
193
Q-5-14-0
245.993
194
Q-5-15-0
169.169
195
Q-5-16-0
VAKSINASI
191.200
196
Q-5-17-0
PASANG INFUS
165.383
197
Q-5-18-0
311.303
198
Q-5-19-0
348.018
199
Q-5-20-0
ABORSI MENGANCAM
233.265
200
Q-5-21-0
ABORSI
230.088
201
Q-5-22-0
245.993
202
Q-5-23-0
301.160
460.986
- 1174 No
Kode
INA-CBG
203
Q-5-24-0
205.688
204
Q-5-25-0
320.767
205
Q-5-26-0
BRONKIAL AKUT
454.023
206
Q-5-27-0
323.105
207
Q-5-28-0
262.191
208
Q-5-29-0
742.307
209
Q-5-30-0
860.253
210
Q-5-31-0
FRAKTUR
306.904
211
Q-5-32-0
SALURAN KEMIH AKUT
355.464
212
Q-5-33-0
HEMATOLOGI AKUT
372.170
213
Q-5-34-0
INFEKSI VIRUS HIV
528.693
214
Q-5-35-0
INFEKSI AKUT
599.523
215
Q-5-36-0
698.184
216
Q-5-37-0
356.109
217
Q-5-38-0
PARU AKUT
474.883
218
Q-5-39-0
303.890
219
Q-5-40-0
298.165
220
Q-5-41-0
412.767
221
Q-5-42-0
323.626
222
Q-5-43-0
466.040
223
Q-5-44-0
380.353
224
T-2-10-0
197.283
225
U-2-10-0
2.632.963
226
U-2-11-0
3.129.569
227
U-2-12-0
344.334
228
U-2-13-0
451.431
229
U-2-14-0
838.554
230
U-2-15-0
476.448
231
U-2-21-0
554.988
232
U-2-22-0
1.072.280
233
U-2-23-0
1.405.034
234
U-2-24-0
1.184.138
235
U-2-25-0
451.431
236
U-2-31-0
362.769
Deskripsi (INA-CBG)
Tarif
INA-CBG
- 1175 No
Kode
INA-CBG
237
U-2-32-0
451.431
238
U-3-10-0

TENGGOROKAN
431.592
239
U-3-11-0
458.216
240
U-3-12-0
202.622
241
U-3-13-0

TENGGOROKAN
445.380
242
U-3-14-0
409.212
243
U-3-15-0
356.870
244
U-3-16-0
PROSEDUR PADA GIGI
402.484
245
V-2-10-0
246
V-2-11-0
PROSEDUR PADA PENIS
247
V-2-12-0
248
V-2-13-0
624.025
249
V-2-14-0
624.025
250
V-2-15-0
SIRKUMSISI/SUNAT
341.701
251
V-3-10-0
712.640
252
V-3-11-0
253
V-3-12-0
870.379
254
W-2-10-0
PROSEDUR ABORSI
318.709
255
W-2-11-0
814.501
256
W-2-12-0
257
W-2-13-0
258
W-2-21-0
3.030.683
259
W-2-22-0
318.709
260
W-2-23-0
1.063.546
261
W-2-31-0
3.491.299
262
W-2-32-0
2.448.607
263
W-2-33-0
1.040.690
264
W-2-34-0
353.957
265
W-3-10-0
860.253
266
W-3-11-0
687.661
267
W-3-12-0
318.709
268
Z-3-10-0
3.608.207
269
Z-3-11-0

SALURAN EMPEDU
2.757.820
270
Z-3-12-0
Deskripsi (INA-CBG)
Tarif
INA-CBG
3.926.697
442.832
1.413.138
1.507.603
1.507.603
241.793
460.489
- 1176 No
Kode
INA-CBG
271
Z-3-13-0
272
Z-3-14-0
DIAGNOSTIK TIDUR
555.630
273
Z-3-15-0
362.769
274
Z-3-16-0
275
Z-3-17-0
PENGOBATAN NUKLIR
488.831
276
Z-3-18-0
CT-SCAN KEPALA
470.979
277
Z-3-19-0
CT SCAN LAIN-LAIN
490.198
278
Z-3-20-0
333.396
279
Z-3-21-0
318.709
280
Z-3-22-0
359.315
281
Z-3-23-0
374.258
282
Z-3-24-0
735.343
283
Z-3-25-0
327.521
284
Z-3-26-0
370.163
285
Z-3-27-0
PERAWATAN LUKA
353.405
286
Z-3-28-0
IMAGING PAYUDARA
362.769
287
Z-3-29-0
IMAGING LAIN-LAIN
288
Z-3-30-0
FOTOTERAPI
Deskripsi (INA-CBG)
Tarif
INA-CBG
2.810.031
1.164.378
1.045.566
176.453
- 1177 X.
TARIF INA-CBG RUMAH SAKIT KHUSUS STROKE BUKITTINGGI

TAHUN 2012
a. RawatInap
No
Kode
INA-CBG
A-4-10-i
SEPTIKEMIA RINGAN
2.465.712
A-4-10-ii
SEPTIKEMIA SEDANG
4.214.122
A-4-10-iii
SEPTIKEMIA BERAT
4.990.823
A-4-11-i
6.616.192
A-4-11-ii
10.221.252
A-4-11-iii
16.719.735
A-4-12-i
DEMAM RINGAN
1.929.531
A-4-12-ii
DEMAM SEDANG
3.722.564
A-4-12-iii
DEMAM BERAT
4.260.201
10
A-4-13-i
2.411.914
11
A-4-13-ii
2.894.297
12
A-4-13-iii
3.517.676
13
A-4-14-i
2.270.139
14
A-4-14-ii
3.702.592
15
A-4-14-iii
4.131.985
16
A-4-15-i
INFEKSI HIV RINGAN
3.034.736
17
A-4-15-ii
INFEKSI HIV SEDANG
4.341.445
18
A-4-15-iii
INFEKSI HIV BERAT
8.121.630
19
B-1-01-i
32.410.848
20
B-1-01-ii
35.757.830
21
B-1-01-iii
62.726.592
22
B-1-10-i
4.201.956
23
B-1-10-ii
10.708.609
24
B-1-10-iii
24.822.063
25
B-1-11-i
3.825.409
26
B-1-11-ii
9.602.136
27
B-1-11-iii
28
B-1-12-i
8.159.734
29
B-1-12-ii
17.488.307
30
B-1-12-iii
20.792.261
31
B-1-13-i
Deskripsi (INA-CBG)
Tarif
INA-CBG
12.038.696
5.346.892
- 1178 No
Kode
INA-CBG
32
B-1-13-ii
33
B-1-13-iii
12.839.969
34
B-1-14-i
7.260.703
35
B-1-14-ii
8.075.368
36
B-1-14-iii
37
B-4-10-i
2.031.434
38
B-4-10-ii
2.942.823
39
B-4-10-iii
4.960.105
40
B-4-11-i
4.904.644
41
B-4-11-ii
7.456.284
42
B-4-11-iii
8.030.676
43
B-4-12-i
4.303.489
44
B-4-12-ii
6.101.288
45
B-4-12-iii
46
B-4-13-i
2.894.297
47
B-4-13-ii
4.213.587
48
B-4-13-iii
6.962.980
49
B-4-14-i
3.726.807
50
B-4-14-ii
4.187.904
51
B-4-14-iii
5.327.413
52
C-4-10-i
3.791.118
53
C-4-10-ii
7.365.745
54
C-4-10-iii
LEUKEMIA AKUT BERAT
55
C-4-11-i
3.813.852
56
C-4-11-ii
4.369.985
57
C-4-11-iii
8.825.025
58
C-4-12-i
RADIOTERAPI RINGAN
1.929.531
59
C-4-12-ii
RADIOTERAPI SEDANG
7.145.966
60
C-4-12-iii
RADIOTERAPI BERAT
61
C-4-13-i
KEMOTERAPI RINGAN
1.929.531
62
C-4-13-ii
KEMOTERAPI SEDANG
3.859.062
63
C-4-13-iii
KEMOTERAPI BERAT
5.049.297
64
C-4-14-i
3.365.561
65
C-4-14-ii
4.917.973
Deskripsi (INA-CBG)
Tarif
INA-CBG
8.709.312
12.632.953
11.595.357
10.870.035
14.507.743
- 1179 No
Kode
INA-CBG
66
C-4-14-iii
67
D-1-10-i
20.739.219
68
D-1-10-ii
31.587.421
69
D-1-10-iii
42.809.587
70
D-1-11-i
5.676.707
71
D-1-11-ii
12.996.234
72
D-1-11-iii
20.370.614
73
D-1-20-i
5.198.494
74
D-1-20-ii
14.317.204
75
D-1-20-iii
22.743.409
76
D-4-10-i
2.236.068
77
D-4-10-ii
3.742.430
78
D-4-10-iii
5.236.369
79
D-4-11-i
2.411.914
80
D-4-11-ii
5.461.946
81
D-4-11-iii
8.274.088
82
D-4-12-i
2.499.073
83
D-4-12-ii
3.466.460
84
D-4-12-iii
5.322.751
85
D-4-13-i
1.929.531
86
D-4-13-ii
2.894.297
87
D-4-13-iii
3.999.702
88
D-4-14-i
2.411.914
89
D-4-14-ii
5.427.955
90
D-4-14-iii
6.474.800
91
E-1-01-i
6.221.488
92
E-1-01-ii
8.149.558
93
E-1-01-iii
94
E-1-10-i
4.760.372
95
E-1-10-ii
5.777.974
96
E-1-10-iii
97
E-1-20-i
7.341.114
98
E-1-20-ii
9.832.237
99
E-1-20-iii
Deskripsi (INA-CBG)
Tarif
INA-CBG
7.497.308
16.153.780
12.178.269
21.785.458
- 1180 No
Kode
INA-CBG
100
E-4-10-i
3.012.265
101
E-4-10-ii
4.614.036
102
E-4-10-iii
7.826.228
103
E-4-11-i
2.768.042
104
E-4-11-ii
5.236.659
105
E-4-11-iii
8.635.493
106
E-4-12-i
2.653.105
107
E-4-12-ii
4.341.445
108
E-4-12-iii
6.975.048
109
E-4-13-i
3.488.684
110
E-4-13-ii
5.990.095
111
E-4-13-iii
112
F-4-10-i
SCHIZOFRENIA RINGAN
4.265.576
113
F-4-10-ii
SCHIZOFRENIA SEDANG
4.737.059
114
F-4-10-iii
SCHIZOFRENIA BERAT
7.013.321
115
F-4-11-i
3.931.828
116
F-4-11-ii
4.580.953
117
F-4-11-iii
DEPRESI MAYOR BERAT
5.874.456
118
F-4-12-i
1.920.048
119
F-4-12-ii
2.545.456
120
F-4-12-iii
4.986.000
121
F-4-13-i
3.177.514
122
F-4-13-ii
4.207.846
123
F-4-13-iii
5.425.480
124
F-4-14-i
DEPRESI RINGAN
2.224.260
125
F-4-14-ii
DEPRESI SEDANG
2.853.065
126
F-4-14-iii
DEPRESI BERAT
3.838.926
127
F-4-15-i
2.644.518
128
F-4-15-ii
3.722.935
129
F-4-15-iii
4.649.843
130
F-4-16-i
5.695.776
131
F-4-16-ii
6.621.196
132
F-4-16-iii
8.838.192
133
F-4-17-i
Deskripsi (INA-CBG)
Tarif
INA-CBG
10.364.377
987.529
- 1181 No
Kode
INA-CBG
134
F-4-17-ii
2.894.353
135
F-4-17-iii
3.088.062
136
F-4-18-i
4.936.906
137
F-4-18-ii
5.431.991
138
F-4-18-iii
8.373.888
139
F-4-19-i
3.786.141
140
F-4-19-ii
4.848.251
141
F-4-19-iii
6.036.138
142
G-1-01-i
10.991.319
143
G-1-01-ii
18.604.133
144
G-1-01-iii
36.015.523
145
G-1-10-i
6.007.046
146
G-1-10-ii
8.480.455
147
G-1-10-iii
148
G-1-11-i
6.929.307
149
G-1-11-ii
14.229.853
150
G-1-11-iii
29.796.019
151
G-1-12-i
5.388.959
152
G-1-12-ii
12.337.485
153
G-1-12-iii
17.294.135
154
G-1-13-i
1.056.601
155
G-1-13-ii
2.837.914
156
G-1-13-iii
6.403.530
157
G-1-20-i
6.790.547
158
G-1-20-ii
9.174.251
159
G-1-20-iii
160
G-1-30-i
7.051.246
161
G-1-30-ii
18.404.434
162
G-1-30-iii
23.692.201
163
G-4-10-i
2.894.297
164
G-4-10-ii
3.376.680
165
G-4-10-iii
5.649.386
166
G-4-11-i
5.229.680
167
G-4-11-ii
6.066.431
Deskripsi (INA-CBG)
Tarif
INA-CBG
10.051.151
22.462.075
- 1182 No
Kode
INA-CBG
168
G-4-11-iii
8.890.461
169
G-4-12-i
3.911.344
170
G-4-12-ii
4.928.294
171
G-4-12-iii
7.157.763
172
G-4-13-i
2.672.981
173
G-4-13-ii
4.147.425
174
G-4-13-iii
4.902.845
175
G-4-14-i
4.888.483
176
G-4-14-ii
8.043.205
177
G-4-14-iii
178
G-4-15-i
179
G-4-15-ii
180
G-4-15-iii
181
G-4-16-i
2.962.446
182
G-4-16-ii
4.430.365
183
G-4-16-iii
8.040.321
184
G-4-17-i
4.636.360
185
G-4-17-ii
5.753.927
186
G-4-17-iii
9.643.628
187
G-4-18-i
2.894.302
188
G-4-18-ii
4.544.722
189
G-4-18-iii
4.814.672
190
G-4-19-i
191
G-4-19-ii
192
G-4-19-iii
193
G-4-20-i
1.688.346
194
G-4-20-ii
2.397.453
195
G-4-20-iii
4.088.221
196
G-4-21-i
2.142.526
197
G-4-21-ii
4.437.387
198
G-4-21-iii
5.227.766
199
G-4-22-i
1.929.541
200
G-4-22-ii
2.411.927
201
G-4-22-iii
2.767.111
Deskripsi (INA-CBG)

RINGAN
SEDANG
BERAT
Tarif
INA-CBG
10.070.276
3.554.935
4.506.858
6.822.178
2.639.962
4.888.082
7.291.469
- 1183 No
Kode
INA-CBG
202
G-4-23-i
1.929.543
203
G-4-23-ii
2.411.929
204
G-4-23-iii
3.447.682
205
G-4-24-i
2.369.957
206
G-4-24-ii
2.962.446
207
G-4-24-iii
TRAUMA KEPALA BERAT
6.225.260
208
G-4-25-i
GEGAR OTAK RINGAN
2.369.957
209
G-4-25-ii
GEGAR OTAK SEDANG
2.962.446
210
G-4-25-iii
GEGAR OTAK BERAT
3.699.177
211
G-4-26-i
3.184.453
212
G-4-26-ii
3.611.277
213
G-4-26-iii
6.445.654
214
H-1-20-i
3.730.630
215
H-1-20-ii
6.803.227
216
H-1-20-iii
9.251.964
217
H-1-30-i
3.652.643
218
H-1-30-ii
4.164.012
219
H-1-30-iii
6.947.504
220
H-4-10-i
3.308.682
221
H-4-10-ii
5.386.610
222
H-4-10-iii
8.457.657
223
H-4-11-i
2.650.791
224
H-4-11-ii
2.925.964
225
H-4-11-iii
3.882.132
226
H-4-12-i
3.677.866
227
H-4-12-ii
4.981.910
228
H-4-12-iii
8.311.977
229
I-1-01-i
42.046.422
230
I-1-01-ii
42.971.663
231
I-1-01-iii
67.829.945
232
I-1-02-i
23.327.113
233
I-1-02-ii
30.091.975
234
I-1-02-iii
37.090.109
I-1-03-i

RINGAN
14.222.475
235
Deskripsi (INA-CBG)
Tarif
INA-CBG
- 1184 No
Kode
INA-CBG
236
I-1-03-ii

SEDANG
19.494.351
237
I-1-03-iii
28.591.715
238
I-1-04-i
23.338.875
239
I-1-04-ii
29.979.199
240
I-1-04-iii
63.909.428
Deskripsi (INA-CBG)

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
Tarif
INA-CBG
241
I-1-05-i
242
I-1-05-ii
243
I-1-05-iii
244
I-1-06-i
19.380.656
245
I-1-06-ii
25.360.931
246
I-1-06-iii
27.994.318
247
I-1-07-i
25.487.031
248
I-1-07-ii
31.443.430
249
I-1-07-iii
34.304.578

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
30.874.120
37.048.944
50.979.113
250
I-1-11-i
251
I-1-11-ii
252
I-1-11-iii
253
I-1-12-i
12.392.862
254
I-1-12-ii
16.717.114
255
I-1-12-iii
22.828.956
256
I-1-13-i
7.570.372
257
I-1-13-ii
8.512.220
258
I-1-13-iii
18.537.753
259
I-1-14-i
24.013.204
260
I-1-14-ii
29.844.983
261
I-1-14-iii
39.107.218
262
I-1-15-i
7.641.715
263
I-1-15-ii
14.000.147
264
I-1-15-iii
24.158.025
265
I-1-16-i
266
I-1-16-ii
267
I-1-16-iii
268
I-1-17-i

4.848.255
5.390.774
7.173.478
10.291.373
26.757.571
30.864.201
4.395.294
- 1185 No
Kode
INA-CBG
269
I-1-17-ii
270
I-1-17-iii
271
I-1-20-i
6.944.436
272
I-1-20-ii
11.696.611
273
I-1-20-iii
22.545.537
274
I-1-30-i
275
I-1-30-ii
276
I-1-30-iii
37.637.022
277
I-1-40-i
20.909.038
278
I-1-40-ii
26.952.538
279
I-1-40-iii
32.415.309
280
I-4-10-i
6.080.956
281
I-4-10-ii
9.601.938
282
I-4-10-iii
283
I-4-11-i
6.218.481
284
I-4-11-ii
7.235.742
285
I-4-11-iii
286
I-4-12-i
6.315.582
287
I-4-12-ii
9.012.317
288
I-4-12-iii
289
I-4-13-i
5.673.128
290
I-4-13-ii
8.241.898
291
I-4-13-iii
292
I-4-14-i
3.528.162
293
I-4-14-ii
4.128.471
294
I-4-14-iii
6.397.757
295
I-4-15-i
3.859.062
296
I-4-15-ii
7.430.935
297
I-4-15-iii
8.469.478
298
I-4-16-i
3.004.725
299
I-4-16-ii
4.819.172
300
I-4-16-iii
6.050.180
301
I-4-17-i
HIPERTENSI RINGAN
3.484.266
302
I-4-17-ii
HIPERTENSI SEDANG
4.753.174
Deskripsi (INA-CBG)

RINGAN
SEDANG
Tarif
INA-CBG
9.104.247
52.780.888
11.675.616
24.287.641
13.851.634
11.739.972
10.933.208
13.564.047
- 1186 No
Kode
INA-CBG
303
I-4-17-iii
HIPERTENSI BERAT
5.555.506
304
I-4-18-i
5.131.324
305
I-4-18-ii
7.860.844
306
I-4-18-iii
307
I-4-19-i
4.015.933
308
I-4-19-ii
6.519.286
309
I-4-19-iii
7.467.634
310
I-4-20-i
4.873.904
311
I-4-20-ii
5.615.101
312
I-4-20-iii
7.452.174
313
I-4-21-i
6.481.503
314
I-4-21-ii
8.085.255
315
I-4-21-iii
316
I-4-22-i
3.135.488
317
I-4-22-ii
3.613.021
318
I-4-22-iii
5.271.299
319
I-4-23-i
320
I-4-23-ii
321
I-4-23-iii
322
I-4-24-i
3.810.753
323
I-4-24-ii
9.514.395
324
I-4-24-iii
12.029.234
325
J-1-01-i
30.702.063
326
J-1-01-ii
32.798.902
327
J-1-01-iii
56.037.118
328
J-1-02-i
15.694.286
329
J-1-02-ii
16.812.762
330
J-1-02-iii
24.844.471
331
J-1-10-i
6.124.137
332
J-1-10-ii
14.792.017
333
J-1-10-iii
22.366.748
334
J-1-20-i
5.198.494
335
J-1-20-ii
7.698.562
336
J-1-20-iii
Deskripsi (INA-CBG)

Tarif
INA-CBG
10.597.678
11.030.002
2.399.224
2.945.694
5.755.617
10.101.168
- 1187 No
Kode
INA-CBG
337
J-1-30-i
3.569.507
338
J-1-30-ii
15.318.139
339
J-1-30-iii
41.781.753
340
J-4-10-i
3.093.567
341
J-4-10-ii
4.423.429
342
J-4-10-iii
6.691.987
343
J-4-11-i
2.598.998
344
J-4-11-ii
3.617.747
345
J-4-11-iii
5.184.323
346
J-4-12-i
EMBOLI PARU RINGAN
2.984.575
347
J-4-12-ii
EMBOLI PARU SEDANG
3.864.923
348
J-4-12-iii
EMBOLI PARU BERAT
5.161.214
349
J-4-13-i
6.122.306
350
J-4-13-ii
8.999.790
351
J-4-13-iii
352
J-4-14-i
TUMOR PARU RINGAN
4.172.158
353
J-4-14-ii
TUMOR PARU SEDANG
6.988.936
354
J-4-14-iii
TUMOR PARU BERAT
8.309.490
355
J-4-15-i
3.652.566
356
J-4-15-ii
5.143.030
357
J-4-15-iii
6.462.875
358
J-4-16-i
2.494.943
359
J-4-16-ii
4.293.914
360
J-4-16-iii
7.035.738
361
J-4-17-i
2.990.333
362
J-4-17-ii
4.058.750
363
J-4-17-iii
6.509.883
364
J-4-18-i
2.026.659
365
J-4-18-ii
3.100.788
366
J-4-18-iii
3.242.654
367
J-4-19-i
3.789.494
368
J-4-19-ii
5.142.992
369
J-4-19-iii
7.351.618
370
J-4-20-i
4.183.125
Deskripsi (INA-CBG)
Tarif
INA-CBG
14.632.312
- 1188 No
Kode
INA-CBG
371
J-4-20-ii
372
J-4-20-iii
373
J-4-21-i
2.328.423
374
J-4-21-ii
5.187.899
375
J-4-21-iii
7.237.865
376
K-1-10-i
5.198.494
377
K-1-10-ii
9.758.501
378
K-1-10-iii
379
K-1-11-i
6.012.480
380
K-1-11-ii
7.893.660
381
K-1-11-iii
382
K-1-12-i
3.234.254
383
K-1-12-ii
4.215.233
384
K-1-12-iii
8.384.985
385
K-1-13-i
3.673.669
386
K-1-13-ii
6.416.845
387
K-1-13-iii
6.862.584
388
K-1-14-i
5.936.866
389
K-1-14-ii
6.973.522
390
K-1-14-iii
16.454.389
391
K-1-20-i
11.519.263
392
K-1-20-ii
16.077.853
393
K-1-20-iii
32.943.482
394
K-1-30-i
7.582.552
395
K-1-30-ii
10.396.987
396
K-1-30-iii
21.779.861
397
K-1-40-i
7.617.589
398
K-1-40-ii
8.382.400
399
K-1-40-iii
400
K-1-50-i
5.810.382
401
K-1-50-ii
7.524.719
402
K-1-50-iii
PROSEDUR ANAL BERAT
403
K-4-10-i
4.400.947
404
K-4-10-ii
5.265.991
Deskripsi (INA-CBG)
Tarif
INA-CBG
5.540.375
11.043.451
11.428.885
20.032.555
13.901.403
10.683.100
- 1189 No
Kode
INA-CBG
405
K-4-10-iii
406
K-4-11-i
2.174.146
407
K-4-11-ii
3.528.519
408
K-4-11-iii
5.918.020
409
K-4-12-i
2.219.812
410
K-4-12-ii
3.877.512
411
K-4-12-iii
8.530.692
412
K-4-13-i
413
K-4-13-ii
414
K-4-13-iii
415
K-4-14-i
2.514.871
416
K-4-14-ii
3.375.812
417
K-4-14-iii
5.926.851
418
K-4-15-i
2.656.097
419
K-4-15-ii
4.800.615
420
K-4-15-iii
6.737.432
421
K-4-16-i
2.670.307
422
K-4-16-ii
3.536.086
423
K-4-16-iii
4.752.065
424
K-4-17-i
1.929.531
425
K-4-17-ii
3.786.762
426
K-4-17-iii
4.603.387
427
K-4-18-i
2.586.963
428
K-4-18-ii
4.029.164
429
K-4-18-iii
4.684.986
430
L-1-20-i
26.559.552
431
L-1-20-ii
27.354.811
432
L-1-20-iii
38.338.890
433
L-1-30-i
9.097.364
434
L-1-30-ii
17.449.584
435
L-1-30-iii
18.403.866
436
L-1-40-i
4.864.079
437
L-1-40-ii
10.396.987
438
L-1-40-iii
14.914.907
Deskripsi (INA-CBG)

(RINGAN)
(SEDANG)
(BERAT)
Tarif
INA-CBG
17.742.998
3.053.355
3.916.488
6.323.089
- 1190 No
Kode
INA-CBG
439
L-1-50-i
6.498.117
440
L-1-50-ii
11.696.611
441
L-1-50-iii
14.142.857
442
L-4-10-i
3.207.084
443
L-4-10-ii
4.464.308
444
L-4-10-iii
9.188.036
445
L-4-11-i
3.682.187
446
L-4-11-ii
5.044.532
447
L-4-11-iii
448
L-4-12-i
3.634.968
449
L-4-12-ii
5.712.118
450
L-4-12-iii
9.250.570
451
L-4-13-i
2.443.597
452
L-4-13-ii
2.817.612
453
L-4-13-iii
4.226.637
454
L-4-14-i
2.226.856
455
L-4-14-ii
3.309.683
456
L-4-14-iii
6.086.971
457
M-1-01-i
458
M-1-01-ii
459
M-1-01-iii
460
M-1-02-i
8.962.024
461
M-1-02-ii
14.713.940
462
M-1-02-iii
25.282.764
463
M-1-03-i
464
M-1-03-ii
465
M-1-03-iii
466
M-1-04-i
467
M-1-04-ii
468
M-1-04-iii
469
M-1-05-i
470
M-1-05-ii
471
M-1-05-iii
Deskripsi (INA-CBG)

(RINGAN)
(SEDANG)
(BERAT)

RINGAN
SEDANG
BERAT
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
Tarif
INA-CBG
13.680.141
9.501.927
10.605.688
14.898.118
16.895.104
19.772.213
25.731.382
5.911.979
7.579.095
9.483.809
9.209.728
10.643.977
18.129.592
- 1191 No
Kode
INA-CBG
472
M-1-07-i
473
M-1-07-ii
474
M-1-07-iii
475
M-1-10-i
6.353.711
476
M-1-10-ii
23.601.157
477
M-1-10-iii
27.517.258
478
M-1-20-i
6.285.462
479
M-1-20-ii
8.971.933
480
M-1-20-iii
481
M-1-30-i
3.759.646
482
M-1-30-ii
7.768.384
483
M-1-30-iii
PROSEDUR KAKI BERAT
484
M-1-40-i
3.712.652
485
M-1-40-ii
6.110.856
486
M-1-40-iii
9.097.364
487
M-1-50-i
5.031.071
488
M-1-50-ii
9.097.364
489
M-1-50-iii
Deskripsi (INA-CBG)
RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
Tarif
INA-CBG
7.634.068
10.227.266
20.833.910
17.439.481
11.588.792
10.396.987
490
M-1-60-i
3.796.871
491
M-1-60-ii
492
M-1-60-iii
493
M-1-70-i
5.086.281
494
M-1-70-ii
10.378.532
495
M-1-70-iii
16.731.448
496
M-1-80-i
4.098.166
497
M-1-80-ii
6.195.589
498
M-1-80-iii
499
M-4-10-i
2.207.041
500
M-4-10-ii
3.959.954
501
M-4-10-iii
FRAKTUR FEMUR BERAT
8.408.753
502
M-4-11-i
3.434.902
503
M-4-11-ii
7.880.177
504
M-4-11-iii
13.987.130
505
M-4-12-i
1.929.531
7.601.361
13.229.058
14.263.851
- 1192 No
Kode
INA-CBG
506
M-4-12-ii
3.510.780
507
M-4-12-iii
7.718.125
508
M-4-13-i
509
M-4-13-ii
510
M-4-13-iii
511
M-4-14-i
3.859.062
512
M-4-14-ii
6.739.094
513
M-4-14-iii
OSTEOMIELITIS BERAT
8.746.498
514
M-4-15-i
3.238.525
515
M-4-15-ii
4.018.091
516
M-4-15-iii
9.033.592
517
M-4-16-i
3.235.396
518
M-4-16-ii
4.727.926
519
M-4-16-iii
9.651.984
520
M-4-17-i
2.771.894
521
M-4-17-ii
3.635.178
522
M-4-17-iii
4.987.692
523
M-4-18-i
3.802.789
524
M-4-18-ii
4.683.034
525
M-4-18-iii
6.449.309
526
M-4-19-i
527
M-4-19-ii
528
M-4-19-iii
529
M-4-20-i
530
M-4-20-ii
531
M-4-20-iii
532
M-4-21-i
533
M-4-21-ii
534
M-4-21-iii
535
N-1-01-i
5.273.352
536
N-1-01-ii
7.132.089
537
N-1-01-iii
538
N-1-11-i
Deskripsi (INA-CBG)

RINGAN
SEDANG

ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
Tarif
INA-CBG
4.791.369
5.363.967
14.253.121
2.827.425
4.526.027
7.222.171
2.107.874
2.894.297
3.207.563
2.019.861
3.387.672
6.994.550
15.122.150
9.097.364
- 1193 No
Kode
INA-CBG
539
N-1-11-ii
13.102.903
540
N-1-11-iii
20.793.974
541
N-1-12-i
542
N-1-12-ii

SEDANG
12.200.677
543
N-1-12-iii
22.236.495
544
N-1-20-i
7.100.475
545
N-1-20-ii
14.077.718
546
N-1-20-iii
16.103.634
547
N-1-30-i
8.447.269
548
N-1-30-ii
12.836.678
549
N-1-30-iii
14.148.902
550
N-1-40-i
7.611.816
551
N-1-40-ii
10.318.088
552
N-1-40-iii
12.000.234
553
N-4-10-i
2.968.881
554
N-4-10-ii
4.344.170
555
N-4-10-iii
8.560.961
556
N-4-11-i
2.484.473
557
N-4-11-ii
4.198.699
558
N-4-11-iii
4.804.683
559
N-4-12-i
2.402.370
560
N-4-12-ii
3.376.466
561
N-4-12-iii
5.306.895
562
N-4-13-i
BATU URIN RINGAN
3.424.153
563
N-4-13-ii
BATU URIN SEDANG
4.128.240
564
N-4-13-iii
Deskripsi (INA-CBG)
BATU URIN BERAT

Tarif
INA-CBG
3.898.870
10.166.724
565
N-4-14-i
1.688.158
566
N-4-14-ii
567
N-4-14-iii
568
N-4-15-i
3.335.249
569
N-4-15-ii
4.577.000
570
N-4-15-iii
5.223.183
571
N-4-16-i
3.349.652
572
N-4-16-ii
4.322.644
2.599.552
4.215.644
- 1194 No
Kode
INA-CBG
573
N-4-16-iii
574
Deskripsi (INA-CBG)
Tarif
INA-CBG
8.621.464
O-6-10-i
4.166.347
575
O-6-10-ii
4.625.280
576
O-6-10-iii
5.699.912

RINGAN
SEDANG
BERAT
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
2.061.289
584
O-6-13-ii
2.408.092
585
O-6-13-iii
2.994.782
586
P-8-01-i
587
P-8-01-ii
588
P-8-01-iii
589
P-8-02-i
590
P-8-02-ii
591
P-8-02-iii
592
P-8-03-i
593
P-8-03-ii
594
P-8-03-iii
595
P-8-04-i
596
P-8-04-ii
597
P-8-04-iii
598
P-8-05-i
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii
603
P-8-06-iii
604
P-8-07-i

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
RINGAN
2.630.270
4.285.481
7.262.561
2.908.872
3.493.548
4.389.143
48.969.190
60.591.713
71.117.686
79.009.456
90.631.979
103.553.516
3.249.058
4.839.352
8.794.927
39.029.993
50.652.515
72.622.957
21.223.244
30.081.088
44.320.445
2.972.034
7.797.740
14.295.857
5.640.065
- 1195 No
Kode
INA-CBG
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
2.712.866
614
P-8-11-ii
16.494.057
615
P-8-11-iii
16.839.610
616
P-8-12-i
3.655.032
617
P-8-12-ii
5.682.940
618
P-8-12-iii
6.704.668
619
P-8-13-i
1.889.118
620
P-8-13-ii
3.495.797
621
P-8-13-iii
5.228.339
622
P-8-14-i
623
P-8-14-ii
624
P-8-14-iii
625
P-8-15-i
2.595.722
626
P-8-15-ii
5.188.165
627
P-8-15-iii
6.094.303
628
P-8-16-i
2.349.742
629
P-8-16-ii
3.333.209
630
P-8-16-iii
4.326.669
631
P-8-17-i
1.548.009
632
P-8-17-ii
5.151.314
633
P-8-17-iii
634
S-4-10-i
1.929.531
635
S-4-10-ii
2.411.914
636
S-4-10-iii
3.135.074
637
S-4-11-i
1.205.957
Deskripsi (INA-CBG)
SEDANG
BERAT
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
AKUT LAIN RINGAN
AKUT LAIN SEDANG
AKUT LAIN BERAT

RINGAN
SEDANG
BERAT
Tarif
INA-CBG
13.927.397
18.727.551
4.433.924
6.294.579
8.037.479
2.750.801
3.984.936
7.823.604
3.451.614
7.047.220
7.730.774
10.397.598
- 1196 No
Kode
INA-CBG
638
S-4-11-ii
1.929.531
639
S-4-11-iii
2.969.501
640
S-4-12-i
1.487.339
641
S-4-12-ii
2.034.296
642
S-4-12-iii
3.891.807
643
S-4-13-i
2.311.564
644
S-4-13-ii
3.807.926
645
S-4-13-iii
7.377.715
646
S-4-14-i
1.187.464
647
S-4-14-ii
2.522.572
648
S-4-14-iii
4.783.695
649
S-4-15-i
898.090
650
S-4-15-ii
1.695.002
651
S-4-15-iii
2.195.421
652
S-4-16-i
LUKA BAKAR RINGAN
3.686.874
653
S-4-16-ii
LUKA BAKAR SEDANG
6.414.754
654
S-4-16-iii
LUKA BAKAR BERAT
655
S-4-17-i
2.421.872
656
S-4-17-ii
2.820.520
657
S-4-17-iii
4.357.023
658
T-1-10-i
2.500.041
659
T-1-10-ii
3.357.385
660
T-1-10-iii
6.108.178
661
T-4-10-i
662
T-4-10-ii
663
T-4-10-iii
664
T-4-11-i
665
T-4-11-ii
666
T-4-11-iii
2.741.370
667
T-4-12-i
1.779.878
668
T-4-12-ii
2.652.064
669
T-4-12-iii
4.084.242
670
U-1-10-i
1.815.176
671
U-1-10-ii
3.703.978
Deskripsi (INA-CBG)

RINGAN
SEDANG
Tarif
INA-CBG
11.454.540
821.201
1.565.027
2.275.124
1.081.497
1.701.969
- 1197 No
Kode
INA-CBG
672
U-1-10-iii
673
U-1-11-i
7.797.740
674
U-1-11-ii
10.396.987
675
U-1-11-iii
23.496.064
676
U-1-12-i
6.409.794
677
U-1-12-ii
11.696.611
678
U-1-12-iii
15.188.270
679
U-1-13-i
5.198.494
680
U-1-13-ii
6.498.117
681
U-1-13-iii
682
U-1-14-i
3.858.245
683
U-1-14-ii
4.734.842
684
U-1-14-iii
5.610.921
685
U-1-15-i
2.266.094
686
U-1-15-ii
3.219.962
687
U-1-15-iii
6.345.064
688
U-1-20-i
5.861.399
689
U-1-20-ii
9.213.909
690
U-1-20-iii
691
U-1-30-i
5.028.058
692
U-1-30-ii
6.787.878
693
U-1-30-iii
694
U-4-10-i
4.680.282
695
U-4-10-ii
11.732.485
696
U-4-10-iii
17.115.140
697
U-4-11-i
2.172.018
698
U-4-11-ii
2.894.297
699
U-4-11-iii
5.384.177
700
U-4-12-i
1.929.531
701
U-4-12-ii
3.025.658
702
U-4-12-iii
4.810.659
703
U-4-13-i
704
U-4-13-ii
705
U-4-13-iii
Deskripsi (INA-CBG)

RINGAN
SEDANG
Tarif
INA-CBG
15.994.524
11.309.974
19.135.576
10.396.987
1.929.531
2.203.771
3.365.744
- 1198 No
Kode
INA-CBG
706
U-4-14-i
2.411.914
707
U-4-14-ii
2.894.297
708
U-4-14-iii
4.879.183
709
U-4-15-i
2.078.375
710
U-4-15-ii
2.737.136
711
U-4-15-iii
3.712.275
712
V-1-10-i
6.411.311
713
V-1-10-ii
7.277.402
714
V-1-10-iii
715
V-1-11-i
6.498.117
716
V-1-11-ii
7.252.008
717
V-1-11-iii
718
V-1-12-i
4.720.644
719
V-1-12-ii
14.410.509
720
V-1-12-iii
16.206.507
721
V-1-13-i
7.154.967
722
V-1-13-ii
13.596.490
723
V-1-13-iii
15.595.481
724
V-1-14-i
8.625.395
725
V-1-14-ii
12.544.899
726
V-1-14-iii
16.973.736
727
V-1-15-i
3.898.870
728
V-1-15-ii
6.084.443
729
V-1-15-iii
730
V-4-10-i
6.547.920
731
V-4-10-ii
8.457.421
732
V-4-10-iii
733
V-4-11-i
3.329.863
734
V-4-11-ii
4.865.462
735
V-4-11-iii
8.027.689
736
W-1-01-i
737
W-1-01-ii
738
W-1-01-iii
739
W-1-10-i
Deskripsi (INA-CBG)

RINGAN
SEDANG
BERAT
Tarif
INA-CBG
12.346.422
10.739.113
10.123.224
16.163.617
9.791.427
11.793.309
21.353.972
2.599.247
- 1199 No
Kode
INA-CBG
740
W-1-10-ii
5.088.844
741
W-1-10-iii
8.323.734
742
W-1-11-i
2.832.343
743
W-1-11-ii
5.198.494
744
W-1-11-iii
7.797.740
745
W-1-12-i
2.573.609
746
W-1-12-ii
2.926.144
747
W-1-12-iii
4.494.927
748
W-1-13-i
2.300.229
749
W-1-13-ii
2.497.386
750
W-1-13-iii
3.354.450
751
W-1-20-i
8.346.356
752
W-1-20-ii
10.396.987
753
W-1-20-iii
11.696.611
754
W-1-30-i
4.556.274
755
W-1-30-ii
6.498.117
756
W-1-30-iii
757
W-4-10-i
3.397.839
758
W-4-10-ii
4.592.560
759
W-4-10-iii
8.255.644
760
W-4-11-i
2.411.914
761
W-4-11-ii
4.047.649
762
W-4-11-iii
4.886.856
763
W-4-12-i
1.929.531
764
W-4-12-ii
3.297.843
765
W-4-12-iii
3.978.702
766
W-4-13-i
ABORTUS RINGAN
1.058.178
767
W-4-13-ii
ABORTUS SEDANG
1.447.148
768
W-4-13-iii
ABORTUS BERAT
1.929.531
769
W-4-14-i
1.447.148
770
W-4-14-ii
1.929.531
771
W-4-14-iii
2.342.043
772
W-4-15-i
1.447.148
773
W-4-15-ii
1.555.324
Deskripsi (INA-CBG)
Tarif
INA-CBG
19.326.050
- 1200 No
Kode
INA-CBG
774
W-4-15-iii
1.967.761
775
W-4-16-i
1.628.532
776
W-4-16-ii
2.580.097
777
W-4-16-iii
3.288.278
778
W-4-17-i
1.447.148
779
W-4-17-ii
1.929.531
780
W-4-17-iii
3.650.289
781
Z-4-10-i
REHABILITASI RINGAN
3.344.180
782
Z-4-10-ii
REHABILITASI SEDANG
4.438.916
783
Z-4-10-iii
REHABILITASI BERAT
6.305.904
784
Z-4-11-i
3.887.352
785
Z-4-11-ii
4.679.513
786
Z-4-11-iii
7.315.775
787
Z-4-12-i
1.503.534
788
Z-4-12-ii
3.966.057
789
Z-4-12-iii
5.040.231
Deskripsi (INA-CBG)
Tarif
INA-CBG
b. RawatJalan
- 1201 -
No
Kode INACBG
B-2-10-0
1.474.420
B-2-11-0
1.912.554
B-2-12-0
3.556.646
B-2-13-0
2.939.223
B-2-14-0
2.455.467
B-3-10-0
B-3-11-0
B-3-12-0
C-3-10-0
1.075.957
10
C-3-11-0
1.701.667
11
C-3-12-0
385.764
12
C-3-13-0
374.604
13
C-3-14-0
3.189.007
14
C-3-15-0
2.922.852
15
C-3-16-0
662.832
16
C-3-17-0
439.704
17
C-3-18-0
194.946
18
C-3-19-0
275.693
19
C-3-20-0
20
C-3-21-0
21
C-3-22-0
22
C-3-23-0
23
D-2-10-0
1.895.596
24
D-2-11-0
PROSEDUR LIMPA
2.373.610
25
D-2-21-0
1.990.786
26
D-2-22-0
436.918
27
D-3-10-0
316.470
28
D-3-11-0
821.648
29
E-2-10-0
487.395
30
E-2-21-0
353.345
31
E-2-22-0

THYROGLOSSAL
353.345
32
E-3-10-0
410.917
33
F-3-10-0
TERAPI SHOCK
573.216
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
860.898
1.919.689
394.433
5.490.429
314.615
1.381.326
223.745
- 1202 No
Kode INACBG
34
F-5-10-0
702.376
35
F-5-11-0
TERAPI KELOMPOK
463.152
36
F-5-12-0
592.682
37
F-5-13-0
501.962
38
F-5-14-0
336.749
39
F-5-15-0
315.914
40
F-5-16-0
329.055
41
G-2-10-0
PROSEDUR KRANIOTOMI
277.090
42
G-2-11-0
1.303.534
43
G-2-12-0
1.889.151
44
G-2-13-0
463.453
45
G-2-21-0
845.264
46
G-2-22-0
767.153
47
G-2-31-0
1.265.875
48
G-2-32-0
648.890
49
G-3-10-0
257.550
50
G-3-11-0
343.008
51
G-3-12-0
562.028
52
G-3-13-0
562.095
53
H-2-21-0
54
H-2-22-0
353.345
55
H-2-23-0
353.345
56
H-2-31-0
57
H-2-32-0
234.315
58
H-2-33-0
353.345
59
H-2-34-0
1.010.018
60
H-2-35-0
332.824
61
H-2-36-0
1.796.506
62
H-2-37-0
1.912.460
63
H-3-10-0
665.396
64
H-3-11-0
349.925
65
H-3-12-0
365.339
66
H-3-13-0
354.722
67
I-2-11-0
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
1.359.179
2.251.368
4.090.704
- 1203 No
Kode INACBG
68
I-2-12-0
2.876.211
69
I-2-13-0
3.655.492
70
I-2-14-0
6.469.442
71
I-2-15-0
72
I-2-16-0

PENGGANTIAN ALAT
4.086.271
73
I-2-17-0
1.347.126
74
I-2-21-0
3.154.020
75
I-2-22-0
2.970.062
76
I-2-23-0
77
I-2-31-0
4.727.178
78
I-2-32-0
6.181.479
79
I-2-41-0
4.144.758
80
I-2-42-0

PERKUTAN LAIN
4.818.967
81
I-3-10-0
PROSEDUR RESUSITASI
611.725
82
I-3-11-0
322.867
83
I-3-12-0
84
I-3-13-0
616.276
85
I-3-14-0
395.012
86
I-3-15-0
349.925
87
J-2-10-0
88
J-2-21-0
89
J-2-22-0
1.759.955
90
J-2-31-0
2.282.819
91
J-2-32-0
1.698.796
92
J-3-10-0
353.345
93
J-3-11-0
998.490
94
J-3-12-0
385.764
95
J-3-13-0
567.749
96
J-3-14-0
602.727
97
J-3-15-0
528.544
98
J-3-16-0
602.727
99
J-3-17-0
353.345
100
K-2-10-0
1.017.048
101
K-2-11-0
2.171.812
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
389.060
607.814
1.876.382
2.166.508
349.241
- 1204 No
Kode INACBG
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
102
K-2-12-0
1.667.145
103
K-2-13-0
2.713.370
104
K-2-14-0
353.345
105
K-2-21-0
353.345
106
K-2-22-0
4.541.324
107
K-2-31-0
1.527.016
108
K-2-32-0
109
K-2-41-0
110
K-2-42-0
111
K-2-51-0
112
K-2-52-0
607.814
113
K-2-53-0
353.345
114
K-3-10-0
672.392
115
K-3-11-0
404.239
116
K-3-12-0
409.949
117
K-3-13-0
353.345
118
K-3-14-0
946.972
119
K-3-15-0
457.306
120
K-3-16-0
605.960
121
L-2-21-0
2.083.311
122
L-2-22-0
1.335.388
123
L-2-31-0
602.727
124
L-2-32-0
607.814
125
L-2-41-0
126
L-2-42-0
127
L-2-51-0
2.724.867
128
L-2-52-0
2.084.613
129
L-2-53-0
353.345
130
L-3-10-0
480.580
131
L-3-11-0
466.676
132
L-3-12-0
355.418
133
M-2-10-0
2.787.738
134
M-2-21-0
2.496.612
135
M-2-22-0
607.814
353.345
1.682.040
480.580
1.114.621
1.820.028
408.203
- 1205 No
Kode INACBG
136
M-2-31-0
PROSEDUR BUNION
137
M-2-32-0
480.580
138
M-2-41-0
480.580
139
M-2-42-0
165.621
140
M-2-51-0
353.345
141
M-2-52-0
353.345
142
M-2-61-0
PROSEDUR ARTROSKOPI
143
M-2-62-0
144
M-2-63-0
1.741.298
145
M-2-64-0
2.374.770
146
M-2-65-0
353.345
147
M-2-71-0
1.753.205
148
M-2-72-0
1.691.917
149
M-2-81-0
2.523.009
150
M-2-82-0
1.832.804
151
M-2-83-0
353.345
152
M-2-84-0
353.345
153
M-3-10-0
154
M-3-11-0
155
M-3-12-0
156
M-3-13-0
412.260
157
M-3-14-0
704.622
158
M-3-15-0
310.429
159
M-3-16-0
353.345
160
M-3-17-0
385.764
161
N-2-11-0
4.668.033
162
N-2-12-0
2.700.411
163
N-2-21-0
2.686.177
164
N-2-22-0
607.814
165
N-2-23-0
607.814
166
N-2-24-0
1.964.252
167
N-2-31-0
1.653.582
168
N-2-32-0
607.814
169
N-2-41-0
607.814
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
1.516.441
1.731.929
353.345
1.008.515
559.160
1.264.497
- 1206 No
Kode INACBG
170
N-2-42-0
171
N-3-10-0
607.814
172
N-3-11-0
704.240
173
N-3-12-0
544.197
174
N-3-13-0
607.814
175
N-3-14-0
522.991
176
N-3-15-0
PROSEDUR DIALISIS
177
O-7-10-0
178
O-7-11-0
179
O-7-12-0
180
O-7-13-0
249.540
181
P-9-10-0

AKUT LAIN
332.824
182
P-9-11-0
332.824
183
P-9-12-0
332.824
184
P-9-13-0
332.824
185
P-9-14-0
332.824
186
P-9-15-0
212.149
187
P-9-16-0
332.824
188
P-9-17-0
331.393
189
Q-5-10-0
433.776
190
Q-5-11-0
325.103
191
Q-5-12-0
GIGI
286.537
192
Q-5-13-0
MEDICAL CHECK-UP
217.756
193
Q-5-14-0
239.603
194
Q-5-15-0
164.775
195
Q-5-16-0
VAKSINASI
186.233
196
Q-5-17-0
PASANG INFUS
161.087
197
Q-5-18-0
303.216
198
Q-5-19-0
338.977
199
Q-5-20-0
ABORSI MENGANCAM
227.205
200
Q-5-21-0
ABORSI
224.111
201
Q-5-22-0
239.603
202
Q-5-23-0
293.337
203
Q-5-24-0
200.345
DESKRIPSI (INA-CBG)

KURETASE
Tarif
INA-CBG
1.027.931
1.341.081
223.903
1.233.092
449.010
- 1207 No
Kode INACBG
204
Q-5-25-0
312.434
205
Q-5-26-0
BRONKIAL AKUT
442.228
206
Q-5-27-0
314.711
207
Q-5-28-0
255.380
208
Q-5-29-0
723.023
209
Q-5-30-0
837.906
210
Q-5-31-0
FRAKTUR
298.931
211
Q-5-32-0
SALURAN KEMIH AKUT
346.230
212
Q-5-33-0
HEMATOLOGI AKUT
362.501
213
Q-5-34-0
INFEKSI VIRUS HIV
514.958
214
Q-5-35-0
INFEKSI AKUT
583.949
215
Q-5-36-0
680.046
216
Q-5-37-0
346.858
217
Q-5-38-0
PARU AKUT
462.547
218
Q-5-39-0
295.996
219
Q-5-40-0
290.419
220
Q-5-41-0
402.045
221
Q-5-42-0
315.219
222
Q-5-43-0
453.933
223
Q-5-44-0
370.473
224
T-2-10-0
192.158
225
U-2-10-0
2.564.563
226
U-2-11-0
3.048.269
227
U-2-12-0
335.389
228
U-2-13-0
439.704
229
U-2-14-0
816.770
230
U-2-15-0
464.071
231
U-2-21-0
540.570
232
U-2-22-0
1.044.425
233
U-2-23-0
1.368.534
234
U-2-24-0
1.153.376
235
U-2-25-0
439.704
236
U-2-31-0
353.345
237
U-2-32-0
439.704
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
- 1208 No
Kode INACBG
238
U-3-10-0
239
U-3-11-0
240
U-3-12-0
197.359
241
U-3-13-0

TENGGOROKAN
433.810
242
U-3-14-0
398.582
243
U-3-15-0
347.599
244
U-3-16-0
PROSEDUR PADA GIGI
392.028
245
V-2-10-0
246
V-2-11-0
PROSEDUR PADA PENIS
247
V-2-12-0
248
V-2-13-0
607.814
249
V-2-14-0
607.814
250
V-2-15-0
SIRKUMSISI/SUNAT
332.824
251
V-3-10-0
694.127
252
V-3-11-0
253
V-3-12-0
847.768
254
W-2-10-0
PROSEDUR ABORSI
310.429
255
W-2-11-0
793.341
256
W-2-12-0
257
W-2-13-0
258
W-2-21-0
2.951.951
259
W-2-22-0
310.429
260
W-2-23-0
1.035.918
261
W-2-31-0
3.400.602
262
W-2-32-0
2.384.997
263
W-2-33-0
1.013.655
264
W-2-34-0
344.762
265
W-3-10-0
837.905
266
W-3-11-0
669.797
267
W-3-12-0
310.429
268
Z-3-10-0
3.514.473
269
Z-3-11-0

SALURAN EMPEDU
2.686.177
270
Z-3-12-0
271
Z-3-13-0
DESKRIPSI (INA-CBG)
TENGGOROKAN
PROSEDUR KECIL LAIN-LAIN PADA TELINGA, HIDUNG, MULUT DAN
TENGGOROKAN
Tarif
INA-CBG
420.380
446.312
3.824.689
431.328
1.376.428
1.468.438
1.468.438
235.511
448.527
2.737.032
- 1209 No
Kode INACBG
272
Z-3-14-0
DIAGNOSTIK TIDUR
541.196
273
Z-3-15-0
353.345
274
Z-3-16-0
275
Z-3-17-0
PENGOBATAN NUKLIR
476.132
276
Z-3-18-0
CT-SCAN KEPALA
458.744
277
Z-3-19-0
CT SCAN LAIN-LAIN
477.463
278
Z-3-20-0
324.735
279
Z-3-21-0
310.429
280
Z-3-22-0
349.981
281
Z-3-23-0
364.536
282
Z-3-24-0
716.240
283
Z-3-25-0
319.012
284
Z-3-26-0
360.547
285
Z-3-27-0
PERAWATAN LUKA
344.225
286
Z-3-28-0
IMAGING PAYUDARA
353.345
287
Z-3-29-0
IMAGING LAIN-LAIN
288
Z-3-30-0
FOTOTERAPI
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
1.134.130
1.018.404
171.869
- 1210 XI.
TARIF INA-CBG RUMAH SAKIT KETERGANTUNGAN OBAT

JAKARTA TAHUN 2012
a. RawatInap
No
Kode
INA-CBG
A-4-10-i
SEPTIKEMIA RINGAN
5.314.967
A-4-10-ii
SEPTIKEMIA SEDANG
6.084.209
A-4-10-iii
SEPTIKEMIA BERAT
9.538.892
A-4-11-i
9.552.237
A-4-11-ii
14.757.102
A-4-11-iii
24.139.394
A-4-12-i
DEMAM RINGAN
3.747.176
A-4-12-ii
DEMAM SEDANG
5.374.513
A-4-12-iii
DEMAM BERAT
6.150.736
10
A-4-13-i
4.683.970
11
A-4-13-ii
5.620.764
12
A-4-13-iii
6.831.374
13
A-4-14-i
3.747.176
14
A-4-14-ii
5.951.298
15
A-4-14-iii
6.776.873
16
A-4-15-i
INFEKSI HIV RINGAN
5.620.764
17
A-4-15-ii
INFEKSI HIV SEDANG
8.431.146
18
A-4-15-iii
INFEKSI HIV BERAT
11.725.738
19
B-1-01-i
62.314.931
20
B-1-01-ii
68.750.029
21
B-1-01-iii
120.601.698
22
B-1-10-i
8.078.919
23
B-1-10-ii
20.588.978
24
B-1-10-iii
35.837.264
25
B-1-11-i
5.522.997
26
B-1-11-ii
13.863.243
27
B-1-11-iii
17.381.066
28
B-1-12-i
11.780.751
29
B-1-12-ii
25.249.032
30
B-1-12-iii
30.729.023
31
B-1-13-i
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
7.719.664
- 1211 No
Kode
INA-CBG
32
B-1-13-ii
12.574.213
33
B-1-13-iii
18.537.918
34
B-1-14-i
10.482.761
35
B-1-14-ii
11.658.945
36
B-1-14-iii
18.239.034
37
B-4-10-i
2.931.683
38
B-4-10-ii
4.683.970
39
B-4-10-iii
7.161.234
40
B-4-11-i
7.081.161
41
B-4-11-ii
10.765.133
42
B-4-11-iii
11.594.422
43
B-4-12-i
6.213.233
44
B-4-12-ii
8.808.836
45
B-4-12-iii
46
B-4-13-i
5.620.764
47
B-4-13-ii
8.771.510
48
B-4-13-iii
49
B-4-14-i
5.620.764
50
B-4-14-ii
6.557.558
51
B-4-14-iii
8.748.442
52
C-4-10-i
5.473.490
53
C-4-10-ii
10.634.416
54
C-4-10-iii
LEUKEMIA AKUT BERAT
17.799.086
55
C-4-11-i
5.620.764
56
C-4-11-ii
7.494.352
57
C-4-11-iii
58
C-4-12-i
RADIOTERAPI RINGAN
3.747.176
59
C-4-12-ii
RADIOTERAPI SEDANG
10.317.107
60
C-4-12-iii
RADIOTERAPI BERAT
20.945.794
61
C-4-13-i
KEMOTERAPI RINGAN
3.747.176
62
C-4-13-ii
KEMOTERAPI SEDANG
7.494.352
63
C-4-13-iii
KEMOTERAPI BERAT
9.805.805
64
C-4-14-i
4.859.084
65
C-4-14-ii
7.100.405
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
17.120.764
13.313.292
12.741.275
- 1212 No
Kode
INA-CBG
66
C-4-14-iii
10.824.362
67
D-1-10-i
39.874.396
68
D-1-10-ii
60.731.764
69
D-1-10-iii
82.308.135
70
D-1-11-i
8.195.839
71
D-1-11-ii
21.376.253
72
D-1-11-iii
30.286.638
73
D-1-20-i
10.095.546
74
D-1-20-ii
22.714.978
75
D-1-20-iii
41.061.084
76
D-4-10-i
3.599.393
77
D-4-10-ii
7.267.851
78
D-4-10-iii
9.367.940
79
D-4-11-i
8.196.947
80
D-4-11-ii
14.650.151
81
D-4-11-iii
20.056.933
82
D-4-12-i
4.804.860
83
D-4-12-ii
6.664.812
84
D-4-12-iii
85
D-4-13-i
3.747.176
86
D-4-13-ii
5.620.764
87
D-4-13-iii
6.557.558
88
D-4-14-i
4.514.890
89
D-4-14-ii
10.541.164
90
D-4-14-iii
12.574.150
91
E-1-01-i
8.982.377
92
E-1-01-ii
11.766.059
93
E-1-01-iii
26.668.046
94
E-1-10-i
9.152.561
95
E-1-10-ii
11.109.061
96
E-1-10-iii
23.414.630
97
E-1-20-i
10.598.855
98
E-1-20-ii
14.195.454
99
E-1-20-iii
31.453.115
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
10.233.823
- 1213 No
Kode
INA-CBG
100
E-4-10-i
4.683.970
101
E-4-10-ii
6.661.591
102
E-4-10-iii
103
E-4-11-i
3.996.406
104
E-4-11-ii
7.560.514
105
E-4-11-iii
106
E-4-12-i
4.775.147
107
E-4-12-ii
8.295.330
108
E-4-12-iii
109
E-4-13-i
5.036.845
110
E-4-13-ii
8.648.298
111
E-4-13-iii
14.963.740
112
G-1-01-i
17.378.547
113
G-1-01-ii
29.415.286
114
G-1-01-iii
56.944.708
115
G-1-10-i
8.672.772
116
G-1-10-ii
12.243.797
117
G-1-10-iii
14.511.515
118
G-1-11-i
10.004.301
119
G-1-11-ii
20.544.586
120
G-1-11-iii
43.018.495
121
G-1-12-i
7.780.399
122
G-1-12-ii
17.812.448
123
G-1-12-iii
31.417.252
124
G-1-13-i
2.051.934
125
G-1-13-ii
5.511.268
126
G-1-13-iii
127
G-1-20-i
9.803.964
128
G-1-20-ii
13.245.477
129
G-1-20-iii
32.429.992
130
G-1-30-i
12.504.074
131
G-1-30-ii
32.636.831
132
G-1-30-iii
42.013.688
133
G-4-10-i
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
12.733.500
12.467.636
13.545.638
12.435.743
5.620.764
- 1214 No
Kode
INA-CBG
134
G-4-10-ii
135
G-4-10-iii
136
G-4-11-i
9.273.858
137
G-4-11-ii
10.757.675
138
G-4-11-iii
15.765.558
139
G-4-12-i
6.936.029
140
G-4-12-ii
8.739.397
141
G-4-12-iii
142
G-4-13-i
3.859.160
143
G-4-13-ii
6.557.558
144
G-4-13-iii
7.751.965
145
G-4-14-i
7.057.829
146
G-4-14-ii
11.612.510
147
G-4-14-iii
14.539.127
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
6.557.558
10.018.130
12.692.934
148
G-4-15-i
149
G-4-15-ii
150
G-4-15-iii
151
G-4-16-i
4.683.970
152
G-4-16-ii
7.004.919
153
G-4-16-iii
154
G-4-17-i
6.693.821
155
G-4-17-ii
8.307.327
156
G-4-17-iii
157
G-4-18-i
5.620.764
158
G-4-18-ii
8.059.203
159
G-4-18-iii
8.537.904

RINGAN
SEDANG
BERAT
7.223.893
8.728.992
10.786.653
12.712.677
13.923.148
160
G-4-19-i
4.683.970
161
G-4-19-ii
162
G-4-19-iii
163
G-4-20-i
3.278.779
164
G-4-20-ii
4.655.870
165
G-4-20-iii
7.939.349
166
G-4-21-i
3.799.355
167
G-4-21-ii
7.868.844
9.492.695
14.160.088
- 1215 No
Kode
INA-CBG
168
G-4-21-iii
9.270.426
169
G-4-22-i
3.747.176
170
G-4-22-ii
4.683.970
171
G-4-22-iii
5.373.738
172
G-4-23-i
3.747.176
173
G-4-23-ii
4.683.970
174
G-4-23-iii
6.695.403
175
G-4-24-i
3.747.176
176
G-4-24-ii
4.683.970
177
G-4-24-iii
TRAUMA KEPALA BERAT
9.842.856
178
G-4-25-i
GEGAR OTAK RINGAN
3.560.549
179
G-4-25-ii
GEGAR OTAK SEDANG
4.482.809
180
G-4-25-iii
GEGAR OTAK BERAT
5.848.826
181
G-4-26-i
5.620.764
182
G-4-26-ii
6.557.558
183
G-4-26-iii
184
H-1-20-i
5.386.159
185
H-1-20-ii
9.822.271
186
H-1-20-iii
187
H-1-30-i
5.273.563
188
H-1-30-ii
6.011.862
189
H-1-30-iii
190
H-4-10-i
5.620.764
191
H-4-10-ii
9.367.940
192
H-4-10-iii
193
H-4-11-i
3.827.123
194
H-4-11-ii
4.276.240
195
H-4-11-iii
6.114.623
196
H-4-12-i
5.309.980
197
H-4-12-ii
7.192.715
198
H-4-12-iii
12.000.554
199
I-1-01-i
80.840.832
200
I-1-01-ii
82.619.752
201
I-1-01-iii
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
12.517.461
13.357.675
10.030.574
15.272.509
130.413.693
- 1216 No
Kode
INA-CBG
202
I-1-02-i
44.850.028
203
I-1-02-ii
57.856.536
204
I-1-02-iii
71.311.544
205
I-1-03-i
206
I-1-03-ii
207
I-1-03-iii
55.525.503
208
I-1-04-i
33.695.887
209
I-1-04-ii
43.282.965
210
I-1-04-iii
92.270.294
DESKRIPSI (INA-CBG)

RINGAN
SEDANG

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
Tarif
INA-CBG
27.620.243
37.858.297
211
I-1-05-i
212
I-1-05-ii
213
I-1-05-iii
214
I-1-06-i
27.981.143
215
I-1-06-ii
42.230.187
216
I-1-06-iii
54.365.349
217
I-1-07-i
36.797.322
218
I-1-07-ii
45.396.972
219
I-1-07-iii
49.527.802

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
59.360.331
71.232.397
98.015.329
220
I-1-11-i
6.999.748
221
I-1-11-ii
222
I-1-11-iii
223
I-1-12-i
21.453.035
224
I-1-12-ii
29.767.088
225
I-1-12-iii
41.518.061
226
I-1-13-i
12.619.432
227
I-1-13-ii
14.681.936
228
I-1-13-iii
26.764.188
229
I-1-14-i
46.169.146
230
I-1-14-ii
57.381.653
231
I-1-14-iii
75.189.753
232
I-1-15-i
9.046.939
233
I-1-15-ii
26.500.808
234
I-1-15-iii
235
I-1-16-i
7.783.020
10.356.827
137.172.140
19.786.777
- 1217 No
Kode
INA-CBG
DESKRIPSI (INA-CBG)
Tarif
INA-CBG

236
I-1-16-ii
237
I-1-16-iii
238
I-1-17-i
6.345.778
239
I-1-17-ii
13.144.408
240
I-1-17-iii
76.203.281
241
I-1-20-i
7.571.659
242
I-1-20-ii
13.628.986
243
I-1-20-iii
18.171.983

RINGAN
SEDANG
51.445.620
59.341.260
244
I-1-30-i
22.448.201
245
I-1-30-ii
246
I-1-30-iii
72.363.070
247
I-1-40-i
30.187.770
248
I-1-40-ii
41.924.329
249
I-1-40-iii
52.533.105
250
I-4-10-i
8.779.481
251
I-4-10-ii
13.862.958
252
I-4-10-iii
19.998.526
253
I-4-11-i
10.410.168
254
I-4-11-ii
12.882.624
255
I-4-11-iii
22.799.186
256
I-4-12-i
9.118.225
257
I-4-12-ii
13.011.682
258
I-4-12-iii
15.785.000
259
I-4-13-i
260
I-4-13-ii
11.899.376
261
I-4-13-iii
24.356.644
262
I-4-14-i
5.093.842
263
I-4-14-ii
5.960.548
264
I-4-14-iii
9.236.867
265
I-4-15-i
7.494.352
266
I-4-15-ii
10.728.536
267
I-4-15-iii
12.227.950
268
I-4-16-i
46.696.794
8.190.673
5.620.764
- 1218 No
Kode
INA-CBG
269
I-4-16-ii
270
I-4-16-iii
271
I-4-17-i
HIPERTENSI RINGAN
5.030.467
272
I-4-17-ii
HIPERTENSI SEDANG
7.123.643
273
I-4-17-iii
HIPERTENSI BERAT
8.666.252
274
I-4-18-i
7.408.433
275
I-4-18-ii
11.349.224
276
I-4-18-iii
15.300.573
277
I-4-19-i
5.798.070
278
I-4-19-ii
9.497.057
279
I-4-19-iii
280
I-4-20-i
7.036.779
281
I-4-20-ii
8.106.896
282
I-4-20-iii
283
I-4-21-i
9.357.777
284
I-4-21-ii
11.673.220
285
I-4-21-iii
15.924.748
286
I-4-22-i
6.089.161
287
I-4-22-ii
7.016.536
288
I-4-22-iii
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
9.109.323
11.476.128
11.320.406
10.759.199
10.236.935
289
I-4-23-i
4.612.883
290
I-4-23-ii
291
I-4-23-iii
292
I-4-24-i
5.501.837
293
I-4-24-ii
13.736.565
294
I-4-24-iii
17.367.405
295
J-1-01-i
45.184.284
296
J-1-01-ii
49.215.786
297
J-1-01-iii
80.904.516
298
J-1-02-i
22.658.885
299
J-1-02-ii
24.273.703
300
J-1-02-iii
35.869.616
301
J-1-10-i
8.841.824
302
J-1-10-ii
21.356.219
5.663.557
11.066.074
- 1219 No
Kode
INA-CBG
303
J-1-10-iii
304
J-1-20-i
7.642.166
305
J-1-20-ii
11.114.926
306
J-1-20-iii
16.713.416
307
J-1-30-i
5.153.534
308
J-1-30-ii
25.238.865
309
J-1-30-iii
76.119.308
310
J-4-10-i
5.947.866
311
J-4-10-ii
8.504.735
312
J-4-10-iii
313
J-4-11-i
3.752.347
314
J-4-11-ii
5.223.181
315
J-4-11-iii
7.484.952
316
J-4-12-i
EMBOLI PARU RINGAN
5.738.313
317
J-4-12-ii
EMBOLI PARU SEDANG
7.430.919
318
J-4-12-iii
EMBOLI PARU BERAT
9.923.242
319
J-4-13-i
8.839.181
320
J-4-13-ii
12.993.596
321
J-4-13-iii
21.125.643
322
J-4-14-i
TUMOR PARU RINGAN
6.023.623
323
J-4-14-ii
TUMOR PARU SEDANG
10.090.392
324
J-4-14-iii
TUMOR PARU BERAT
11.996.964
325
J-4-15-i
5.620.764
326
J-4-15-ii
10.171.596
327
J-4-15-iii
12.709.205
328
J-4-16-i
4.683.970
329
J-4-16-ii
6.557.558
330
J-4-16-iii
331
J-4-17-i
5.849.554
332
J-4-17-ii
7.903.753
333
J-4-17-iii
334
J-4-18-i
5.262.943
335
J-4-18-ii
7.328.125
336
J-4-18-iii
7.600.885
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
37.813.811
12.866.394
11.829.145
10.333.451
- 1220 No
Kode
INA-CBG
337
J-4-19-i
6.557.558
338
J-4-19-ii
7.494.352
339
J-4-19-iii
340
J-4-20-i
6.557.558
341
J-4-20-ii
7.999.009
342
J-4-20-iii
343
J-4-21-i
3.747.176
344
J-4-21-ii
9.244.967
345
J-4-21-iii
13.186.347
346
K-1-10-i
10.095.546
347
K-1-10-ii
14.088.998
348
K-1-10-iii
16.500.642
349
K-1-11-i
8.680.617
350
K-1-11-ii
11.396.602
351
K-1-11-iii
28.922.333
352
K-1-12-i
4.669.507
353
K-1-12-ii
6.085.813
354
K-1-12-iii
355
K-1-13-i
5.303.921
356
K-1-13-ii
9.264.426
357
K-1-13-iii
9.907.969
358
K-1-14-i
8.571.449
359
K-1-14-ii
10.068.138
360
K-1-14-iii
24.790.676
361
K-1-20-i
16.631.126
362
K-1-20-ii
23.212.666
363
K-1-20-iii
49.583.351
364
K-1-30-i
10.947.435
365
K-1-30-ii
20.191.092
366
K-1-30-iii
31.445.035
367
K-1-40-i
10.998.020
368
K-1-40-ii
12.102.228
369
K-1-40-iii
20.070.381
370
K-1-50-i
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
11.740.781
18.074.876
12.105.961
8.388.836
- 1221 No
Kode
INA-CBG
371
K-1-50-ii
10.863.938
372
K-1-50-iii
PROSEDUR ANAL BERAT
15.423.902
373
K-4-10-i
6.353.940
374
K-4-10-ii
7.602.862
375
K-4-10-iii
376
K-4-11-i
3.747.176
377
K-4-11-ii
5.620.764
378
K-4-11-iii
379
K-4-12-i
3.747.176
380
K-4-12-ii
5.598.223
381
K-4-12-iii
382
K-4-13-i
383
K-4-13-ii
384
K-4-13-iii
385
K-4-14-i
4.683.970
386
K-4-14-ii
6.339.264
387
K-4-14-iii
9.588.742
388
K-4-15-i
4.683.970
389
K-4-15-ii
8.807.141
390
K-4-15-iii
391
K-4-16-i
4.683.970
392
K-4-16-ii
5.620.764
393
K-4-16-iii
6.860.873
394
K-4-17-i
3.747.176
395
K-4-17-ii
5.467.200
396
K-4-17-iii
7.276.285
397
K-4-18-i
3.747.176
398
K-4-18-ii
5.817.172
399
K-4-18-iii
6.881.685
400
L-1-20-i
38.345.793
401
L-1-20-ii
39.890.196
402
L-1-20-iii
61.116.385
403
L-1-30-i
17.392.523
404
L-1-30-ii
25.193.126
DESKRIPSI (INA-CBG)

(RINGAN)
(SEDANG)
(BERAT)
Tarif
INA-CBG
31.483.352
10.214.953
13.435.336
5.620.764
7.280.273
11.907.341
12.530.976
- 1222 No
Kode
INA-CBG
405
L-1-30-iii
406
L-1-40-i
7.022.595
407
L-1-40-ii
15.805.753
408
L-1-40-iii
26.786.575
409
L-1-50-i
12.619.432
410
L-1-50-ii
22.714.978
411
L-1-50-iii
27.465.623
412
L-4-10-i
5.620.764
413
L-4-10-ii
6.557.558
414
L-4-10-iii
415
L-4-11-i
5.316.219
416
L-4-11-ii
7.283.127
417
L-4-11-iii
418
L-4-12-i
5.620.764
419
L-4-12-ii
8.246.965
420
L-4-12-iii
421
L-4-13-i
3.527.984
422
L-4-13-ii
4.067.973
423
L-4-13-iii
6.102.277
424
L-4-14-i
3.747.176
425
L-4-14-ii
5.620.764
426
L-4-14-iii
8.788.166
DESKRIPSI (INA-CBG)

(RINGAN)
(SEDANG)
(BERAT)
Tarif
INA-CBG
26.570.887
13.265.379
19.750.930
13.829.184
427
M-1-01-i
428
M-1-01-ii
429
M-1-01-iii
430
M-1-02-i
12.939.071
431
M-1-02-ii
21.243.494
432
M-1-02-iii
38.470.994
433
M-1-03-i
434
M-1-03-ii
435
M-1-03-iii
436
M-1-04-i
437
M-1-04-ii
438
M-1-04-iii

RINGAN
SEDANG
BERAT
(RINGAN)
(SEDANG)
(BERAT)
18.268.943
20.391.095
28.643.965
32.810.524
38.397.909
39.120.241
8.535.517
10.942.444
13.692.407
- 1223 No
Kode
INA-CBG
439
M-1-05-i
440
M-1-05-ii
441
M-1-05-iii
442
M-1-07-i
443
M-1-07-ii
444
M-1-07-iii
445
M-1-10-i
9.173.275
446
M-1-10-ii
34.074.561
447
M-1-10-iii
41.679.683
448
M-1-20-i
9.074.739
449
M-1-20-ii
12.953.376
450
M-1-20-iii
25.178.539
451
M-1-30-i
5.428.051
452
M-1-30-ii
11.215.734
453
M-1-30-iii
PROSEDUR KAKI BERAT
16.731.510
454
M-1-40-i
5.484.624
455
M-1-40-ii
10.095.546
456
M-1-40-iii
17.667.205
457
M-1-50-i
7.263.693
458
M-1-50-ii
14.621.984
459
M-1-50-iii
20.191.092
460
M-1-60-i
461
M-1-60-ii
462
M-1-60-iii
463
M-1-70-i
7.343.402
464
M-1-70-ii
14.984.178
465
M-1-70-iii
24.156.305
466
M-1-80-i
5.916.795
467
M-1-80-ii
8.944.984
468
M-1-80-iii
469
M-4-10-i
3.747.176
470
M-4-10-ii
5.717.250
471
M-4-10-iii
FRAKTUR FEMUR BERAT
DESKRIPSI (INA-CBG)
(RINGAN)
(SEDANG)
(BERAT)
RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
Tarif
INA-CBG
13.296.697
15.367.418
26.174.899
14.677.692
19.663.521
40.056.456
5.481.796
10.974.591
19.099.671
20.593.671
12.140.277
- 1224 No
Kode
INA-CBG
472
M-4-11-i
4.959.197
473
M-4-11-ii
11.377.136
474
M-4-11-iii
20.194.150
475
M-4-12-i
3.747.176
476
M-4-12-ii
6.817.982
477
M-4-12-iii
DESKRIPSI (INA-CBG)

RINGAN
SEDANG
Tarif
INA-CBG
13.654.634
478
M-4-13-i
479
M-4-13-ii
480
M-4-13-iii
481
M-4-14-i
7.494.352
482
M-4-14-ii
9.729.678
483
M-4-14-iii
OSTEOMIELITIS BERAT
484
M-4-15-i
4.675.674
485
M-4-15-ii
6.234.626
486
M-4-15-iii
487
M-4-16-i
4.683.970
488
M-4-16-ii
7.494.352
489
M-4-16-iii
490
M-4-17-i
4.683.970
491
M-4-17-ii
6.557.558
492
M-4-17-iii
9.157.978
493
M-4-18-i
5.490.340
494
M-4-18-ii
7.494.352
495
M-4-18-iii
9.311.297
496
M-4-19-i
497
M-4-19-ii
498
M-4-19-iii
499
M-4-20-i
500
M-4-20-ii
501
M-4-20-iii
502
M-4-21-i
503
M-4-21-ii
504
M-4-21-iii

ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
6.917.618
9.367.940
20.578.180
14.574.009
15.925.498
13.935.212
4.082.142
6.875.635
13.428.624
3.747.176
5.620.764
6.229.131
3.747.176
4.891.007
11.922.211
- 1225 No
Kode
INA-CBG
505
N-1-01-i
10.138.844
506
N-1-01-ii
13.712.558
507
N-1-01-iii
29.074.703
508
N-1-11-i
13.987.319
509
N-1-11-ii
18.917.533
510
N-1-11-iii
40.110.797
511
N-1-12-i
512
N-1-12-ii

SEDANG
17.614.930
513
N-1-12-iii
32.104.307
514
N-1-20-i
10.251.429
515
N-1-20-ii
20.324.939
516
N-1-20-iii
23.249.888
517
N-1-30-i
12.195.884
518
N-1-30-ii
18.533.167
519
N-1-30-iii
21.334.731
520
N-1-40-i
10.989.685
521
N-1-40-ii
14.896.910
522
N-1-40-iii
17.325.537
523
N-4-10-i
4.683.970
524
N-4-10-ii
6.271.967
525
N-4-10-iii
526
N-4-11-i
3.586.999
527
N-4-11-ii
6.061.942
528
N-4-11-iii
7.025.955
529
N-4-12-i
3.747.176
530
N-4-12-ii
5.620.764
531
N-4-12-iii
9.332.316
532
N-4-13-i
BATU URIN RINGAN
4.943.677
533
N-4-13-ii
BATU URIN SEDANG
5.960.215
534
N-4-13-iii
BATU URIN BERAT
535
N-4-14-i
536
N-4-14-ii
537
N-4-14-iii
538
N-4-15-i
DESKRIPSI (INA-CBG)

Tarif
INA-CBG
7.571.659
13.728.206
14.678.375
3.245.749
4.998.045
8.105.236
4.815.322
- 1226 No
Kode
INA-CBG
539
N-4-15-ii
6.608.119
540
N-4-15-iii
7.541.057
541
N-4-16-i
6.249.622
542
N-4-16-ii
7.494.352
543
N-4-16-iii
544
O-6-10-i
9.227.875
545
O-6-10-ii
10.244.348
546
O-6-10-iii
11.484.037
547
O-6-11-i
548
O-6-11-ii
549
O-6-11-iii
550
O-6-12-i
551
O-6-12-ii
552
O-6-12-iii
553
O-6-13-i
4.208.888
554
O-6-13-ii
6.203.076
555
O-6-13-iii
7.331.078
556
P-8-01-i
557
P-8-01-ii
558
P-8-01-iii
559
P-8-02-i
560
P-8-02-ii
561
P-8-02-iii
562
P-8-03-i
563
P-8-03-ii
564
P-8-03-iii
565
P-8-04-i
566
P-8-04-ii
567
P-8-04-iii
568
P-8-05-i
569
P-8-05-ii
570
P-8-05-iii
DESKRIPSI (INA-CBG)

RINGAN
SEDANG
BERAT

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
Tarif
INA-CBG
15.759.507
4.822.818
6.187.235
10.485.443
4.199.732
5.043.868
6.336.897
94.150.938
116.497.058
136.734.889
114.071.210
130.851.419
149.507.102
6.309.716
8.833.603
13.914.928
56.350.198
73.130.407
104.850.596
30.641.410
43.430.068
63.988.376
- 1227 No
Kode
INA-CBG
571
P-8-06-i
572
P-8-06-ii
573
P-8-06-iii
574
P-8-07-i
575
P-8-07-ii
576
P-8-07-iii
577
P-8-08-i
578
P-8-08-ii
579
P-8-08-iii
580
P-8-10-i
581
P-8-10-ii
582
P-8-10-iii
583
P-8-11-i
11.185.474
584
P-8-11-ii
23.813.567
585
P-8-11-iii
24.312.465
586
P-8-12-i
5.277.013
587
P-8-12-ii
8.204.839
588
P-8-12-iii
9.679.975
589
P-8-13-i
2.727.445
590
P-8-13-ii
5.047.115
591
P-8-13-iii
7.548.501
DESKRIPSI (INA-CBG)
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
AKUT LAIN RINGAN
AKUT LAIN SEDANG
AKUT LAIN BERAT

RINGAN
SEDANG
BERAT
Tarif
INA-CBG
5.047.773
12.701.519
23.626.275
8.833.603
24.767.296
32.810.524
6.401.551
9.087.902
12.829.327
3.971.515
5.753.317
11.295.457
592
P-8-14-i
4.983.325
593
P-8-14-ii
594
P-8-14-iii
595
P-8-15-i
3.747.616
596
P-8-15-ii
7.490.499
597
P-8-15-iii
8.798.751
598
P-8-16-i
3.392.478
599
P-8-16-ii
4.812.375
600
P-8-16-iii
6.246.700
601
P-8-17-i
2.239.028
602
P-8-17-ii
7.437.294
603
P-8-17-iii
10.174.540
11.161.432
15.011.705
- 1228 No
Kode
INA-CBG
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
604
S-4-10-i
3.747.176
605
S-4-10-ii
4.683.970
606
S-4-10-iii
6.088.357
607
S-4-11-i
2.341.985
608
S-4-11-ii
3.564.545
609
S-4-11-iii
5.766.811
610
S-4-12-i
2.810.382
611
S-4-12-ii
3.747.176
612
S-4-12-iii
7.318.531
613
S-4-13-i
3.747.176
614
S-4-13-ii
6.624.167
615
S-4-13-iii
616
S-4-14-i
2.283.085
617
S-4-14-ii
4.850.039
618
S-4-14-iii
9.197.402
619
S-4-15-i
1.726.719
620
S-4-15-ii
3.258.906
621
S-4-15-iii
4.221.041
622
S-4-16-i
LUKA BAKAR RINGAN
6.557.558
623
S-4-16-ii
LUKA BAKAR SEDANG
9.261.408
624
S-4-16-iii
LUKA BAKAR BERAT
625
S-4-17-i
3.496.618
626
S-4-17-ii
4.683.970
627
S-4-17-iii
7.638.137
628
U-1-10-i
3.489.960
629
U-1-10-ii
7.121.477
630
U-1-10-iii
30.751.978
631
U-1-11-i
15.143.319
632
U-1-11-ii
20.191.092
633
U-1-11-iii
33.922.832
634
U-1-12-i
9.254.246
635
U-1-12-ii
22.714.978
636
U-1-12-iii
29.495.829
637
U-1-13-i
10.095.546
13.487.646
16.537.682
- 1229 No
Kode
INA-CBG
638
U-1-13-ii
11.390.515
639
U-1-13-iii
21.964.125
640
U-1-14-i
5.570.405
641
U-1-14-ii
6.836.007
642
U-1-14-iii
8.100.861
643
U-1-15-i
3.271.711
644
U-1-15-ii
4.648.873
645
U-1-15-iii
9.160.791
646
U-1-20-i
8.462.492
647
U-1-20-ii
15.063.235
648
U-1-20-iii
37.161.551
649
U-1-30-i
7.259.342
650
U-1-30-ii
9.800.112
651
U-1-30-iii
652
U-4-10-i
6.757.235
653
U-4-10-ii
16.938.969
654
U-4-10-iii
24.710.267
655
U-4-11-i
3.747.176
656
U-4-11-ii
5.620.764
657
U-4-11-iii
7.773.494
658
U-4-12-i
3.747.176
659
U-4-12-ii
4.368.344
660
U-4-12-iii
6.945.469
661
U-4-13-i
662
U-4-13-ii
663
U-4-13-iii
4.859.348
664
U-4-14-i
4.683.970
665
U-4-14-ii
5.620.764
666
U-4-14-iii
9.415.755
667
U-4-15-i
3.747.176
668
U-4-15-ii
4.683.970
669
U-4-15-iii
6.558.829
670
V-1-10-i
10.954.238
671
V-1-10-ii
12.619.432
DESKRIPSI (INA-CBG)

RINGAN
SEDANG
Tarif
INA-CBG
19.211.037
3.681.324
4.279.754
- 1230 No
Kode
INA-CBG
672
V-1-10-iii
23.976.922
673
V-1-11-i
12.619.432
674
V-1-11-ii
14.083.498
675
V-1-11-iii
20.855.505
676
V-1-12-i
6.815.509
677
V-1-12-ii
26.046.608
678
V-1-12-iii
30.411.788
679
V-1-13-i
10.330.102
680
V-1-13-ii
19.630.157
681
V-1-13-iii
30.286.638
682
V-1-14-i
12.453.057
683
V-1-14-ii
18.111.905
684
V-1-14-iii
24.620.500
685
V-1-15-i
5.870.923
686
V-1-15-ii
11.182.966
687
V-1-15-iii
19.659.440
688
V-4-10-i
9.453.668
689
V-4-10-ii
12.210.542
690
V-4-10-iii
23.336.489
691
V-4-11-i
4.807.544
692
V-4-11-ii
7.024.591
693
V-4-11-iii
DESKRIPSI (INA-CBG)

RINGAN
SEDANG
BERAT
Tarif
INA-CBG
11.590.109
694
W-1-01-i
14.136.535
695
W-1-01-ii
696
W-1-01-iii
697
W-1-10-i
3.937.008
698
W-1-10-ii
7.347.103
699
W-1-10-iii
700
W-1-11-i
4.089.242
701
W-1-11-ii
7.886.621
702
W-1-11-iii
703
W-1-12-i
3.715.691
704
W-1-12-ii
4.224.669
705
W-1-12-iii
6.489.625
17.026.786
37.608.787
12.017.529
15.143.319
- 1231 No
Kode
INA-CBG
706
W-1-13-i
4.422.550
707
W-1-13-ii
4.801.615
708
W-1-13-iii
6.449.455
709
W-1-20-i
12.050.190
710
W-1-20-ii
16.950.400
711
W-1-20-iii
21.413.133
712
W-1-30-i
6.578.195
713
W-1-30-ii
10.492.562
714
W-1-30-iii
27.902.304
715
W-4-10-i
4.905.686
716
W-4-10-ii
6.630.584
717
W-4-10-iii
718
W-4-11-i
4.683.970
719
W-4-11-ii
7.494.352
720
W-4-11-iii
9.107.859
721
W-4-12-i
3.747.176
722
W-4-12-ii
5.152.367
723
W-4-12-iii
5.744.317
724
W-4-13-i
ABORTUS RINGAN
2.054.995
725
W-4-13-ii
ABORTUS SEDANG
2.810.382
726
W-4-13-iii
ABORTUS BERAT
3.747.176
727
W-4-14-i
2.810.382
728
W-4-14-ii
3.614.605
729
W-4-14-iii
4.548.279
730
W-4-15-i
2.343.531
731
W-4-15-ii
2.606.453
732
W-4-15-iii
3.608.882
733
W-4-16-i
2.810.382
734
W-4-16-ii
3.747.176
735
W-4-16-iii
5.108.765
736
W-4-17-i
2.295.396
737
W-4-17-ii
3.747.176
738
W-4-17-iii
7.088.912
739
Z-4-11-i
5.612.429
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
14.988.704
- 1232 No
Kode
INA-CBG
740
Z-4-11-ii
741
Z-4-11-iii
742
Z-4-12-i
2.810.382
743
Z-4-12-ii
5.726.061
744
Z-4-12-iii
7.276.916
745
F-4-10-i
SCHIZOFRENIA RINGAN
6.158.496
746
F-4-10-ii
SCHIZOFRENIA SEDANG
6.839.208
747
F-4-10-iii
SCHIZOFRENIA BERAT
748
F-4-11-i
5.676.641
749
F-4-11-ii
6.613.826
750
F-4-11-iii
DEPRESI MAYOR BERAT
8.481.342
751
F-4-12-i
2.810.382
752
F-4-12-ii
4.012.827
753
F-4-12-iii
8.705.155
754
F-4-13-i
4.587.589
755
F-4-13-ii
6.075.147
756
F-4-13-iii
7.833.126
757
F-4-14-i
DEPRESI RINGAN
3.211.313
758
F-4-14-ii
DEPRESI SEDANG
4.119.159
759
F-4-14-iii
DEPRESI BERAT
5.542.513
760
F-4-15-i
3.818.067
761
F-4-15-ii
5.620.764
762
F-4-15-iii
7.402.891
763
F-4-16-i
8.223.370
764
F-4-16-ii
9.559.462
765
F-4-16-iii
766
F-4-17-i
1.898.679
767
F-4-17-ii
5.564.847
768
F-4-17-iii
5.937.282
769
F-4-18-i
7.127.740
770
F-4-18-ii
7.842.527
771
F-4-18-iii
772
F-4-19-i
5.466.304
773
F-4-19-ii
6.999.743
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
6.756.125
10.689.390
10.125.598
12.760.286
12.089.940
- 1233 No
Kode
INA-CBG
774
F-4-19-iii
8.714.774
775
T-1-10-i
3.609.475
776
T-1-10-ii
4.847.280
777
T-1-10-iii
8.818.783
DESKRIPSI (INA-CBG)

RINGAN
SEDANG
Tarif
INA-CBG
778
T-4-10-i
1.578.887
779
T-4-10-ii
780
T-4-10-iii
781
T-4-11-i
782
T-4-11-ii
783
T-4-11-iii
3.957.898
784
T-4-12-i
3.278.779
785
T-4-12-ii
4.955.694
786
T-4-12-iii
7.709.279
787
Z-4-10-i
REHABILITASI RINGAN
6.429.710
788
Z-4-10-ii
REHABILITASI SEDANG
8.534.512
789
Z-4-10-iii
REHABILITASI BERAT
3.009.009
4.374.283
1.561.429
2.457.245
12.124.089
- 1234 -
b. RawatJalan
No
Kode
INA-CBG
B-2-10-0
1.835.614
B-2-11-0
2.381.079
B-2-12-0
4.427.930
B-2-13-0
3.659.254
B-2-14-0
3.056.992
B-3-10-0
1.071.795
B-3-11-0
2.389.962
B-3-12-0
C-3-10-0
1.339.538
10
C-3-11-0
2.118.530
11
C-3-12-0
480.266
12
C-3-13-0
466.372
13
C-3-14-0
3.970.229
14
C-3-15-0
3.638.873
15
C-3-16-0
825.209
16
C-3-18-0
242.702
17
C-3-19-0
343.230
18
C-3-20-0
19
C-3-21-0
20
C-3-22-0
21
C-3-23-0
22
D-2-10-0
2.359.966
23
D-2-11-0
PROSEDUR LIMPA
2.955.081
24
D-2-21-0
2.478.476
25
D-2-22-0
543.951
26
D-3-10-0
393.997
27
D-3-11-0
28
E-2-10-0
606.794
29
E-2-21-0
439.905
30
E-2-22-0

THYROGLOSSAL
439.905
31
E-3-10-0
511.581
32
G-2-10-0
PROSEDUR KRANIOTOMI
344.969
33
G-2-11-0
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
491.059
6.835.438
391.687
1.719.714
278.556
1.022.930
2.990.339
- 1235 No
Kode
INA-CBG
34
G-2-12-0
4.333.738
35
G-2-13-0
1.063.163
36
G-2-21-0
1.939.029
37
G-2-22-0
1.759.834
38
G-2-31-0
2.903.879
39
G-2-32-0
1.488.526
40
G-3-10-0
590.806
41
G-3-11-0
786.839
42
G-3-12-0
1.289.250
43
G-3-13-0
1.289.397
44
H-2-21-0
1.692.142
45
H-2-22-0
439.905
46
H-2-23-0
439.905
47
H-2-31-0
48
H-2-32-0
291.716
49
H-2-33-0
439.905
50
H-2-34-0
1.257.446
51
H-2-35-0
414.357
52
H-2-36-0
2.236.602
53
H-2-37-0
2.380.962
54
H-3-10-0
828.401
55
H-3-11-0
435.647
56
H-3-12-0
454.838
57
H-3-13-0
441.620
58
I-2-11-0
5.092.818
59
I-2-12-0
3.580.807
60
I-2-13-0
4.550.990
61
I-2-14-0
8.054.284
62
I-2-15-0
63
I-2-16-0

PENGGANTIAN ALAT
5.087.299
64
I-2-17-0
1.677.136
65
I-2-21-0
3.926.672
66
I-2-22-0
3.697.649
67
I-2-23-0
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
2.802.893
484.369
756.713
- 1236 No
Kode
INA-CBG
68
I-2-31-0
5.885.211
69
I-2-32-0
7.695.778
70
I-2-41-0
5.160.114
71
I-2-42-0

PERKUTAN LAIN
5.999.486
72
I-3-10-0
PROSEDUR RESUSITASI
761.581
73
I-3-11-0
401.961
74
I-3-12-0
75
I-3-13-0
767.248
76
I-3-14-0
491.780
77
I-3-15-0
435.647
78
J-2-10-0
79
J-2-21-0
80
J-2-22-0
2.191.098
81
J-2-31-0
2.842.050
82
J-2-32-0
2.114.957
83
J-3-10-0
439.905
84
J-3-11-0
85
J-3-12-0
480.266
86
J-3-13-0
706.832
87
J-3-14-0
750.379
88
J-3-15-0
658.023
89
J-3-16-0
750.379
90
J-3-17-0
439.905
91
K-2-10-0
1.266.197
92
K-2-11-0
2.703.848
93
K-2-12-0
2.075.552
94
K-2-13-0
3.378.073
95
K-2-14-0
439.905
96
K-2-21-0
439.905
97
K-2-22-0
5.653.828
98
K-2-31-0
1.901.095
99
K-2-32-0
100
K-2-41-0
101
K-2-42-0
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
2.336.045
2.697.246
434.795
1.243.094
439.905
2.094.095
598.309
- 1237 No
Kode
INA-CBG
102
K-2-51-0
103
K-2-52-0
756.713
104
K-2-53-0
439.905
105
K-3-10-0
837.110
106
K-3-11-0
503.267
107
K-3-12-0
510.376
108
K-3-13-0
439.905
109
K-3-14-0
1.178.955
110
K-3-15-0
569.334
111
K-3-16-0
754.404
112
L-2-21-0
2.593.667
113
L-2-22-0
1.662.522
114
L-2-31-0
750.379
115
L-2-32-0
756.713
116
L-2-41-0
117
L-2-42-0
118
L-2-51-0
3.392.388
119
L-2-52-0
2.595.288
120
L-2-53-0
439.905
121
L-3-10-0
598.309
122
L-3-11-0
580.999
123
L-3-12-0
442.486
124
M-2-10-0
3.470.660
125
M-2-21-0
3.108.216
126
M-2-22-0
756.713
127
M-2-31-0
PROSEDUR BUNION
128
M-2-32-0
598.309
129
M-2-41-0
598.309
130
M-2-42-0
206.194
131
M-2-51-0
439.905
132
M-2-52-0
439.905
133
M-2-61-0
PROSEDUR ARTROSKOPI
134
M-2-62-0
135
M-2-63-0
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
1.387.674
2.265.887
508.202
1.887.929
2.156.205
439.905
2.167.869
- 1238 No
Kode
INA-CBG
136
M-2-64-0
2.956.526
137
M-2-65-0
439.905
138
M-2-71-0
2.182.693
139
M-2-72-0
2.106.392
140
M-2-81-0
3.141.079
141
M-2-82-0
2.281.792
142
M-2-83-0
439.905
143
M-2-84-0
439.905
144
M-3-10-0
145
M-3-11-0
146
M-3-12-0
147
M-3-13-0
513.253
148
M-3-14-0
877.236
149
M-3-15-0
386.476
150
M-3-16-0
439.905
151
M-3-17-0
480.266
152
N-2-11-0
5.811.578
153
N-2-12-0
3.361.940
154
N-2-21-0
3.344.219
155
N-2-22-0
756.713
156
N-2-23-0
756.713
157
N-2-24-0
2.445.442
158
N-2-31-0
2.058.666
159
N-2-32-0
756.713
160
N-2-41-0
756.713
161
N-2-42-0
1.279.746
162
N-3-10-0
756.713
163
N-3-11-0
876.760
164
N-3-12-0
677.511
165
N-3-13-0
756.713
166
N-3-14-0
651.110
167
N-3-15-0
PROSEDUR DIALISIS
168
O-7-10-0
O-7-11-0

KURETASE
169
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
1.255.574
696.139
1.574.266
1.669.611
278.753
1.535.166
- 1239 No
Kode
INA-CBG
170
O-7-12-0

559.006
171
O-7-13-0
310.671
172
P-9-10-0

AKUT LAIN
414.357
173
P-9-11-0
414.357
174
P-9-12-0
414.357
175
P-9-13-0
414.357
176
P-9-14-0
414.357
177
P-9-15-0
264.120
178
P-9-16-0
414.357
179
P-9-17-0
412.575
180
Q-5-10-0
540.039
181
Q-5-11-0
404.745
182
Q-5-12-0
GIGI
356.731
183
Q-5-13-0
MEDICAL CHECK-UP
271.100
184
Q-5-14-0
298.299
185
Q-5-15-0
205.140
186
Q-5-16-0
VAKSINASI
231.856
187
Q-5-17-0
PASANG INFUS
200.549
188
Q-5-18-0
377.496
189
Q-5-19-0
422.018
190
Q-5-20-0
ABORSI MENGANCAM
282.865
191
Q-5-21-0
ABORSI
279.012
192
Q-5-22-0
298.299
193
Q-5-23-0
365.197
194
Q-5-24-0
249.424
195
Q-5-25-0
388.972
196
Q-5-26-0
BRONKIAL AKUT
550.563
197
Q-5-27-0
391.807
198
Q-5-28-0
317.941
199
Q-5-29-0
900.144
200
Q-5-30-0
201
Q-5-31-0
FRAKTUR
372.161
202
Q-5-32-0
SALURAN KEMIH AKUT
431.047
203
Q-5-33-0
HEMATOLOGI AKUT
451.304
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
1.043.170
- 1240 No
Kode
INA-CBG
204
Q-5-34-0
INFEKSI VIRUS HIV
641.109
205
Q-5-35-0
INFEKSI AKUT
727.001
206
Q-5-36-0
846.640
207
Q-5-37-0
431.829
208
Q-5-38-0
PARU AKUT
575.859
209
Q-5-39-0
368.507
210
Q-5-40-0
361.564
211
Q-5-41-0
500.535
212
Q-5-42-0
392.439
213
Q-5-43-0
565.135
214
Q-5-44-0
461.229
215
U-2-10-0
3.192.814
216
U-2-11-0
3.795.014
217
U-2-12-0
417.551
218
U-2-13-0
547.419
219
U-2-14-0
220
U-2-15-0
577.756
221
U-2-21-0
672.995
222
U-2-22-0
1.300.281
223
U-2-23-0
1.703.788
224
U-2-24-0
1.435.923
225
U-2-25-0
547.419
226
U-2-31-0
439.905
227
U-2-32-0
547.419
228
U-3-10-0

TENGGOROKAN
523.362
229
U-3-11-0
555.647
230
U-3-12-0
245.706
231
U-3-13-0

TENGGOROKAN
540.082
232
U-3-14-0
496.224
233
U-3-15-0
432.751
234
U-3-16-0
PROSEDUR PADA GIGI
488.065
235
V-2-10-0
236
V-2-11-0
PROSEDUR PADA PENIS
237
V-2-12-0
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
1.016.857
4.761.636
536.992
1.713.616
- 1241 No
Kode
INA-CBG
238
V-2-13-0
756.713
239
V-2-14-0
756.713
240
V-2-15-0
SIRKUMSISI/SUNAT
414.357
241
V-3-10-0
864.169
242
V-3-11-0
1.828.166
243
V-3-12-0
1.055.449
244
W-2-10-0
PROSEDUR ABORSI
386.476
245
W-2-11-0
987.689
246
W-2-12-0
247
W-2-13-0
248
W-2-21-0
3.675.101
249
W-2-22-0
386.476
250
W-2-23-0
1.289.690
251
W-2-31-0
4.233.660
252
W-2-32-0
2.969.258
253
W-2-33-0
1.261.974
254
W-2-34-0
255
W-3-10-0
256
W-3-11-0
833.880
257
W-3-12-0
386.476
258
Z-3-10-0
4.375.425
259
Z-3-11-0

SALURAN EMPEDU
3.344.219
260
Z-3-13-0
3.407.533
261
Z-3-15-0
262
Z-3-16-0
263
Z-3-17-0
PENGOBATAN NUKLIR
592.772
264
Z-3-18-0
CT-SCAN KEPALA
571.124
265
Z-3-19-0
CT SCAN LAIN-LAIN
594.429
266
Z-3-20-0
404.286
267
Z-3-21-0
386.476
268
Z-3-22-0
435.717
269
Z-3-23-0
453.837
270
Z-3-24-0
891.700
271
Z-3-25-0
397.162
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
1.828.166
293.205
429.219
1.043.169
439.905
1.411.962
- 1242 No
Kode
INA-CBG
272
Z-3-26-0
448.871
273
Z-3-27-0
PERAWATAN LUKA
428.550
274
Z-3-28-0
IMAGING PAYUDARA
439.905
275
Z-3-29-0
IMAGING LAIN-LAIN
276
Z-3-30-0
FOTOTERAPI
213.972
277
C-3-17-0
547.419
278
F-3-10-0
TERAPI SHOCK
713.639
279
F-5-10-0
874.439
280
F-5-11-0
TERAPI KELOMPOK
576.612
281
F-5-12-0
737.873
282
F-5-13-0
624.929
283
F-5-14-0
419.244
284
F-5-15-0
393.305
285
F-5-16-0
409.665
286
T-2-10-0
239.232
287
Z-3-12-0
558.404
288
Z-3-14-0
DIAGNOSTIK TIDUR
673.775
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
1.267.886
- 1243 XII. TARIF INA-CBG RUMAH SAKIT PENYAKIT INFEKSI PROF. DR.
SULIANTI SAROSOTAHUN 2012
a. RawatInap
No
Kode
INA-CBG
A-4-10-i
SEPTIKEMIA RINGAN
2.465.712
A-4-10-ii
SEPTIKEMIA SEDANG
4.214.122
A-4-10-iii
SEPTIKEMIA BERAT
6.033.013
A-4-13-i
2.962.446
A-4-13-ii
3.554.935
A-4-13-iii
4.320.604
A-4-14-i
2.369.957
A-4-14-ii
3.702.592
A-4-14-iii
4.131.985
10
A-4-15-i
INFEKSI HIV RINGAN
3.554.935
11
A-4-15-ii
INFEKSI HIV SEDANG
5.332.403
12
A-4-15-iii
INFEKSI HIV BERAT
8.121.630
13
A-4-11-i
5.386.658
14
A-4-11-ii
8.321.765
15
A-4-11-iii
9.328.006
16
A-4-12-i
DEMAM RINGAN
1.929.531
17
A-4-12-ii
DEMAM SEDANG
3.030.773
18
A-4-12-iii
DEMAM BERAT
3.468.498
19
B-1-01-i
32.410.848
20
B-1-01-ii
35.757.830
21
B-1-01-iii
62.726.592
22
B-1-10-i
4.201.956
23
B-1-10-ii
10.708.609
24
B-1-10-iii
24.822.063
25
B-1-11-i
3.825.409
26
B-1-11-ii
9.602.136
27
B-1-11-iii
28
B-1-12-i
8.159.734
29
B-1-12-ii
17.488.307
30
B-1-12-iii
20.792.261
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
12.038.696
- 1244 No
Kode
INA-CBG
31
B-1-13-i
5.346.892
32
B-1-13-ii
8.709.312
33
B-1-13-iii
12.839.969
34
B-1-14-i
7.260.703
35
B-1-14-ii
8.075.368
36
B-1-14-iii
37
B-4-10-i
2.031.434
38
B-4-10-ii
2.942.823
39
B-4-10-iii
4.960.105
40
B-4-11-i
4.904.644
41
B-4-11-ii
7.456.284
42
B-4-11-iii
8.030.676
43
B-4-12-i
4.303.489
44
B-4-12-ii
6.101.288
45
B-4-12-iii
46
B-4-13-i
2.894.297
47
B-4-13-ii
4.213.587
48
B-4-13-iii
6.962.980
49
B-4-14-i
3.726.807
50
B-4-14-ii
4.187.904
51
B-4-14-iii
5.327.413
52
C-4-10-i
3.791.118
53
C-4-10-ii
7.365.745
54
C-4-10-iii
LEUKEMIA AKUT BERAT
55
C-4-11-i
3.813.852
56
C-4-11-ii
4.369.985
57
C-4-11-iii
8.825.025
58
C-4-12-i
RADIOTERAPI RINGAN
1.929.531
59
C-4-12-ii
RADIOTERAPI SEDANG
7.145.966
60
C-4-12-iii
RADIOTERAPI BERAT
61
C-4-13-i
KEMOTERAPI RINGAN
1.929.531
62
C-4-13-ii
KEMOTERAPI SEDANG
3.859.062
63
C-4-13-iii
KEMOTERAPI BERAT
5.049.297
64
C-4-14-i
3.365.561
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
12.632.953
11.595.357
10.870.035
14.507.743
- 1245 No
Kode
INA-CBG
65
C-4-14-ii
4.917.973
66
C-4-14-iii
7.497.308
67
D-1-10-i
20.739.219
68
D-1-10-ii
31.587.421
69
D-1-10-iii
42.809.587
70
D-1-11-i
5.676.707
71
D-1-11-ii
12.996.234
72
D-1-11-iii
20.370.614
73
D-1-20-i
5.198.494
74
D-1-20-ii
14.317.204
75
D-1-20-iii
22.743.409
76
D-4-10-i
2.236.068
77
D-4-10-ii
3.742.430
78
D-4-10-iii
5.236.369
79
D-4-11-i
2.411.914
80
D-4-11-ii
5.461.946
81
D-4-11-iii
8.274.088
82
D-4-12-i
2.499.073
83
D-4-12-ii
3.466.460
84
D-4-12-iii
5.322.751
85
D-4-13-i
1.929.531
86
D-4-13-ii
2.894.297
87
D-4-13-iii
3.999.702
88
D-4-14-i
2.411.914
89
D-4-14-ii
5.427.955
90
D-4-14-iii
6.474.800
91
E-1-01-i
6.221.488
92
E-1-01-ii
8.149.558
93
E-1-01-iii
94
E-1-10-i
4.760.372
95
E-1-10-ii
5.777.974
96
E-1-10-iii
97
E-1-20-i
7.341.114
98
E-1-20-ii
9.832.237
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
16.153.780
12.178.269
- 1246 No
Kode
INA-CBG
99
E-1-20-iii
21.785.458
100
E-4-10-i
3.012.265
101
E-4-10-ii
4.614.036
102
E-4-10-iii
7.826.228
103
E-4-11-i
2.768.042
104
E-4-11-ii
5.236.659
105
E-4-11-iii
8.635.493
106
E-4-12-i
2.653.105
107
E-4-12-ii
4.341.445
108
E-4-12-iii
6.975.048
109
E-4-13-i
3.488.684
110
E-4-13-ii
5.990.095
111
E-4-13-iii
112
F-4-10-i
SCHIZOFRENIA RINGAN
4.265.576
113
F-4-10-ii
SCHIZOFRENIA SEDANG
4.737.059
114
F-4-10-iii
SCHIZOFRENIA BERAT
7.013.321
115
F-4-11-i
3.931.828
116
F-4-11-ii
4.580.953
117
F-4-11-iii
DEPRESI MAYOR BERAT
5.874.456
118
F-4-12-i
1.920.048
119
F-4-12-ii
2.545.456
120
F-4-12-iii
4.986.000
121
F-4-13-i
3.177.514
122
F-4-13-ii
4.207.846
123
F-4-13-iii
5.425.480
124
F-4-14-i
DEPRESI RINGAN
2.224.260
125
F-4-14-ii
DEPRESI SEDANG
2.853.065
126
F-4-14-iii
DEPRESI BERAT
3.838.926
127
F-4-15-i
2.644.518
128
F-4-15-ii
3.722.935
129
F-4-15-iii
4.649.843
130
F-4-16-i
5.695.776
131
F-4-16-ii
6.621.196
132
F-4-16-iii
8.838.192
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
10.364.377
- 1247 No
Kode
INA-CBG
133
F-4-17-i
987.529
134
F-4-17-ii
2.894.353
135
F-4-17-iii
3.088.062
136
F-4-18-i
4.936.906
137
F-4-18-ii
5.431.991
138
F-4-18-iii
8.373.888
139
F-4-19-i
3.786.141
140
F-4-19-ii
4.848.251
141
F-4-19-iii
6.036.138
142
G-1-01-i
9.038.820
143
G-1-01-ii
15.299.292
144
G-1-01-iii
29.617.721
145
G-1-10-i
6.007.046
146
G-1-10-ii
8.480.455
147
G-1-10-iii
148
G-1-11-i
6.929.307
149
G-1-11-ii
14.229.853
150
G-1-11-iii
25.992.468
151
G-1-12-i
5.388.959
152
G-1-12-ii
11.696.611
153
G-1-12-iii
17.294.135
154
G-1-13-i
1.067.239
155
G-1-13-ii
2.866.486
156
G-1-13-iii
6.468.000
157
G-1-20-i
6.790.547
158
G-1-20-ii
9.174.251
159
G-1-20-iii
160
G-1-30-i
8.660.731
161
G-1-30-ii
22.605.338
162
G-1-30-iii
29.100.056
163
G-4-10-i
2.894.297
164
G-4-10-ii
3.958.119
165
G-4-10-iii
6.938.885
166
G-4-11-i
6.423.378
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
10.051.151
22.462.075
- 1248 No
Kode
INA-CBG
167
G-4-11-ii
168
G-4-11-iii
169
G-4-12-i
4.804.121
170
G-4-12-ii
6.053.193
171
G-4-12-iii
8.791.542
172
G-4-13-i
2.672.981
173
G-4-13-ii
3.713.942
174
G-4-13-iii
4.335.169
175
G-4-14-i
4.888.483
176
G-4-14-ii
8.043.205
177
G-4-14-iii
178
G-4-15-i
179
G-4-15-ii
180
G-4-15-iii
181
G-4-16-i
2.701.475
182
G-4-16-ii
3.908.633
183
G-4-16-iii
6.877.316
184
G-4-17-i
4.636.360
185
G-4-17-ii
5.753.927
186
G-4-17-iii
9.643.628
187
G-4-18-i
2.918.752
188
G-4-18-ii
5.582.068
189
G-4-18-iii
5.913.632
DESKRIPSI (INA-CBG)

RINGAN
SEDANG
BERAT
Tarif
INA-CBG
7.451.118
10.919.742
10.070.276
3.237.168
4.019.991
5.924.017
190
G-4-19-i
3.242.538
191
G-4-19-ii
192
G-4-19-iii
193
G-4-20-i
1.904.186
194
G-4-20-ii
2.620.430
195
G-4-20-iii
4.328.212
196
G-4-21-i
2.631.558
197
G-4-21-ii
3.657.865
198
G-4-21-iii
6.421.001
199
G-4-22-i
1.929.531
200
G-4-22-ii
2.411.914
5.743.622
8.171.197
- 1249 No
Kode
INA-CBG
201
G-4-22-iii
2.767.096
202
G-4-23-i
2.373.309
203
G-4-23-ii
2.468.822
204
G-4-23-iii
3.514.996
205
G-4-24-i
1.986.986
206
G-4-24-ii
2.880.353
207
G-4-24-iii
TRAUMA KEPALA BERAT
5.563.560
208
G-4-25-i
GEGAR OTAK RINGAN
1.929.531
209
G-4-25-ii
GEGAR OTAK SEDANG
2.411.914
210
G-4-25-iii
GEGAR OTAK BERAT
3.011.733
211
G-4-26-i
3.911.296
212
G-4-26-ii
4.435.540
213
G-4-26-iii
6.510.502
214
H-1-20-i
3.730.630
215
H-1-20-ii
6.803.227
216
H-1-20-iii
9.251.964
217
H-1-30-i
3.652.643
218
H-1-30-ii
4.164.012
219
H-1-30-iii
6.947.504
220
H-4-10-i
3.308.682
221
H-4-10-ii
5.386.610
222
H-4-10-iii
8.457.657
223
H-4-11-i
2.650.791
224
H-4-11-ii
2.925.964
225
H-4-11-iii
3.882.132
226
H-4-12-i
3.677.866
227
H-4-12-ii
4.981.910
228
H-4-12-iii
8.311.977
229
I-1-01-i
42.046.422
230
I-1-01-ii
42.971.663
231
I-1-01-iii
67.829.945
232
I-1-02-i
23.327.113
233
I-1-02-ii
30.091.975
234
I-1-02-iii
37.090.109
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
- 1250 No
Kode
INA-CBG
235
I-1-03-i
236
I-1-03-ii
237
I-1-03-iii
28.591.715
238
I-1-04-i
23.338.875
239
I-1-04-ii
29.979.199
240
I-1-04-iii
63.909.428
DESKRIPSI (INA-CBG)
RINGAN
SEDANG

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
Tarif
INA-CBG
14.222.475
19.494.351
241
I-1-05-i
242
I-1-05-ii
243
I-1-05-iii
244
I-1-06-i
19.380.656
245
I-1-06-ii
25.360.931
246
I-1-06-iii
27.994.318
247
I-1-07-i
25.487.031
248
I-1-07-ii
31.443.430
249
I-1-07-iii
34.304.578

JANTUNG RINGAN
JANTUNG SEDANG
JANTUNG BERAT
30.874.120
37.048.944
50.979.113
250
I-1-11-i
251
I-1-11-ii
252
I-1-11-iii
253
I-1-12-i
12.392.862
254
I-1-12-ii
16.717.114
255
I-1-12-iii
22.828.956
256
I-1-13-i
7.570.372
257
I-1-13-ii
8.512.220
258
I-1-13-iii
18.537.753
259
I-1-14-i
24.013.204
260
I-1-14-ii
29.844.983
261
I-1-14-iii
39.107.218
262
I-1-15-i
7.641.715
263
I-1-15-ii
14.000.147
264
I-1-15-iii
24.158.025
265
I-1-16-i
266
I-1-16-ii
267
I-1-16-iii

4.848.255
5.390.774
7.173.478
10.291.373
26.757.571
30.864.201
- 1251 No
Kode
INA-CBG
268
I-1-17-i
4.395.294
269
I-1-17-ii
9.104.247
270
I-1-17-iii
271
I-1-20-i
6.944.436
272
I-1-20-ii
11.696.611
273
I-1-20-iii
22.545.537
DESKRIPSI (INA-CBG)

RINGAN
SEDANG
Tarif
INA-CBG
52.780.888
274
I-1-30-i
11.675.616
275
I-1-30-ii
276
I-1-30-iii
37.637.022
277
I-1-40-i
20.909.038
278
I-1-40-ii
26.952.538
279
I-1-40-iii
32.415.309
280
I-4-10-i
6.080.956
281
I-4-10-ii
9.601.938
282
I-4-10-iii
283
I-4-11-i
6.218.481
284
I-4-11-ii
7.235.742
285
I-4-11-iii
286
I-4-12-i
6.315.582
287
I-4-12-ii
9.012.317
288
I-4-12-iii
289
I-4-13-i
5.673.128
290
I-4-13-ii
8.241.898
291
I-4-13-iii
292
I-4-14-i
3.528.162
293
I-4-14-ii
4.128.471
294
I-4-14-iii
6.397.757
295
I-4-15-i
3.859.062
296
I-4-15-ii
7.430.935
297
I-4-15-iii
8.469.478
298
I-4-16-i
3.004.725
299
I-4-16-ii
4.819.172
300
I-4-16-iii
6.050.180
301
I-4-17-i
HIPERTENSI RINGAN
3.484.266
24.287.641
13.851.634
11.739.972
10.933.208
13.564.047
- 1252 No
Kode
INA-CBG
302
I-4-17-ii
HIPERTENSI SEDANG
4.753.174
303
I-4-17-iii
HIPERTENSI BERAT
5.555.506
304
I-4-18-i
5.131.324
305
I-4-18-ii
7.860.844
306
I-4-18-iii
307
I-4-19-i
4.015.933
308
I-4-19-ii
6.519.286
309
I-4-19-iii
7.467.634
310
I-4-20-i
4.873.904
311
I-4-20-ii
5.615.101
312
I-4-20-iii
7.452.174
313
I-4-21-i
6.481.503
314
I-4-21-ii
8.085.255
315
I-4-21-iii
316
I-4-22-i
3.135.488
317
I-4-22-ii
3.613.021
318
I-4-22-iii
5.271.299
DESKRIPSI (INA-CBG)

Tarif
INA-CBG
10.597.678
11.030.002
319
I-4-23-i
2.399.224
320
I-4-23-ii
321
I-4-23-iii
322
I-4-24-i
3.810.753
323
I-4-24-ii
9.514.395
324
I-4-24-iii
12.029.234
325
J-1-01-i
30.702.063
326
J-1-01-ii
32.798.902
327
J-1-01-iii
56.037.118
328
J-1-02-i
15.694.286
329
J-1-02-ii
16.812.762
330
J-1-02-iii
24.844.471
331
J-1-10-i
6.124.137
332
J-1-10-ii
14.792.017
333
J-1-10-iii
22.366.748
334
J-1-20-i
5.198.494
335
J-1-20-ii
7.698.562
2.945.694
5.755.617
- 1253 No
Kode
INA-CBG
336
J-1-20-iii
337
J-1-30-i
3.569.507
338
J-1-30-ii
15.318.139
339
J-1-30-iii
41.781.753
340
J-4-10-i
3.093.567
341
J-4-10-ii
4.423.429
342
J-4-10-iii
6.691.987
343
J-4-11-i
2.598.998
344
J-4-11-ii
3.617.747
345
J-4-11-iii
5.184.323
346
J-4-12-i
EMBOLI PARU RINGAN
2.984.575
347
J-4-12-ii
EMBOLI PARU SEDANG
3.864.923
348
J-4-12-iii
EMBOLI PARU BERAT
5.161.214
349
J-4-13-i
6.122.306
350
J-4-13-ii
8.999.790
351
J-4-13-iii
352
J-4-14-i
TUMOR PARU RINGAN
4.172.158
353
J-4-14-ii
TUMOR PARU SEDANG
6.988.936
354
J-4-14-iii
TUMOR PARU BERAT
8.309.490
355
J-4-15-i
3.652.566
356
J-4-15-ii
5.143.030
357
J-4-15-iii
6.462.875
358
J-4-16-i
2.494.943
359
J-4-16-ii
4.293.914
360
J-4-16-iii
7.035.738
361
J-4-17-i
2.990.333
362
J-4-17-ii
4.058.750
363
J-4-17-iii
6.509.883
364
J-4-18-i
2.026.659
365
J-4-18-ii
3.100.788
366
J-4-18-iii
3.242.654
367
J-4-19-i
3.789.494
368
J-4-19-ii
5.142.992
369
J-4-19-iii
7.351.618
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
10.101.168
14.632.312
- 1254 No
Kode
INA-CBG
370
J-4-20-i
4.183.125
371
J-4-20-ii
5.540.375
372
J-4-20-iii
373
J-4-21-i
2.328.423
374
J-4-21-ii
5.187.899
375
J-4-21-iii
7.237.865
376
K-1-10-i
5.198.494
377
K-1-10-ii
9.758.501
378
K-1-10-iii
379
K-1-11-i
6.012.480
380
K-1-11-ii
7.893.660
381
K-1-11-iii
382
K-1-12-i
3.234.254
383
K-1-12-ii
4.215.233
384
K-1-12-iii
8.384.985
385
K-1-13-i
3.673.669
386
K-1-13-ii
6.416.845
387
K-1-13-iii
6.862.584
388
K-1-14-i
5.936.866
389
K-1-14-ii
6.973.522
390
K-1-14-iii
16.454.389
391
K-1-20-i
11.519.263
392
K-1-20-ii
16.077.853
393
K-1-20-iii
32.943.482
394
K-1-30-i
7.582.552
395
K-1-30-ii
10.396.987
396
K-1-30-iii
21.779.861
397
K-1-40-i
7.617.589
398
K-1-40-ii
8.382.400
399
K-1-40-iii
400
K-1-50-i
5.810.382
401
K-1-50-ii
7.524.719
402
K-1-50-iii
PROSEDUR ANAL BERAT
403
K-4-10-i
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
11.043.451
11.428.885
20.032.555
13.901.403
10.683.100
4.400.947
- 1255 No
Kode
INA-CBG
404
K-4-10-ii
405
K-4-10-iii
406
K-4-11-i
2.174.146
407
K-4-11-ii
3.528.519
408
K-4-11-iii
5.918.020
409
K-4-12-i
2.219.812
410
K-4-12-ii
3.877.512
411
K-4-12-iii
8.530.692
412
K-4-13-i
413
K-4-13-ii
414
K-4-13-iii
415
K-4-14-i
2.514.871
416
K-4-14-ii
3.375.812
417
K-4-14-iii
5.926.851
418
K-4-15-i
2.656.097
419
K-4-15-ii
4.800.615
420
K-4-15-iii
6.737.432
421
K-4-16-i
2.670.307
422
K-4-16-ii
3.536.086
423
K-4-16-iii
4.752.065
424
K-4-17-i
1.929.531
425
K-4-17-ii
3.786.762
426
K-4-17-iii
4.603.387
427
K-4-18-i
2.586.963
428
K-4-18-ii
4.029.164
429
K-4-18-iii
4.684.986
430
L-1-20-i
26.559.552
431
L-1-20-ii
27.354.811
432
L-1-20-iii
38.338.890
433
L-1-30-i
9.097.364
434
L-1-30-ii
17.449.584
435
L-1-30-iii
18.403.866
436
L-1-40-i
4.864.079
437
L-1-40-ii
10.396.987
DESKRIPSI (INA-CBG)

(RINGAN)
(SEDANG)
(BERAT)
Tarif
INA-CBG
5.265.991
17.742.998
3.053.355
3.916.488
6.323.089
- 1256 No
Kode
INA-CBG
438
L-1-40-iii
439
L-1-50-i
6.498.117
440
L-1-50-ii
11.696.611
441
L-1-50-iii
14.142.857
442
L-4-10-i
3.207.084
443
L-4-10-ii
4.464.308
444
L-4-10-iii
9.188.036
445
L-4-11-i
3.682.187
446
L-4-11-ii
5.044.532
447
L-4-11-iii
448
L-4-12-i
3.634.968
449
L-4-12-ii
5.712.118
450
L-4-12-iii
9.250.570
451
L-4-13-i
2.443.597
452
L-4-13-ii
2.817.612
453
L-4-13-iii
4.226.637
454
L-4-14-i
2.226.856
455
L-4-14-ii
3.309.683
456
L-4-14-iii
6.086.971
457
M-1-01-i
458
M-1-01-ii
459
M-1-01-iii
460
M-1-02-i
8.962.024
461
M-1-02-ii
14.713.940
462
M-1-02-iii
25.282.764
463
M-1-03-i
464
M-1-03-ii
465
M-1-03-iii
466
M-1-04-i
467
M-1-04-ii
468
M-1-04-iii
469
M-1-05-i
470
M-1-05-ii
DESKRIPSI (INA-CBG)

(RINGAN)
(SEDANG)
(BERAT)

RINGAN
SEDANG
BERAT
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
Tarif
INA-CBG
14.914.907
13.680.141
9.501.927
10.605.688
14.898.118
16.895.104
19.772.213
25.731.382
5.911.979
7.579.095
9.483.809
9.209.728
10.643.977
- 1257 No
Kode
INA-CBG
471
M-1-05-iii
472
M-1-07-i
473
M-1-07-ii
474
M-1-07-iii
475
M-1-10-i
6.353.711
476
M-1-10-ii
23.601.157
477
M-1-10-iii
27.517.258
478
M-1-20-i
6.285.462
479
M-1-20-ii
8.971.933
480
M-1-20-iii
481
M-1-30-i
3.759.646
482
M-1-30-ii
7.768.384
483
M-1-30-iii
PROSEDUR KAKI BERAT
484
M-1-40-i
3.712.652
485
M-1-40-ii
6.110.856
486
M-1-40-iii
9.097.364
487
M-1-50-i
5.031.071
488
M-1-50-ii
9.097.364
489
M-1-50-iii
DESKRIPSI (INA-CBG)
(BERAT)
RINGAN
SEDANG
BERAT

(RINGAN)
(SEDANG)
(BERAT)
Tarif
INA-CBG
18.129.592
7.634.068
10.227.266
20.833.910
17.439.481
11.588.792
10.396.987
490
M-1-60-i
3.796.871
491
M-1-60-ii
492
M-1-60-iii
493
M-1-70-i
5.086.281
494
M-1-70-ii
10.378.532
495
M-1-70-iii
16.731.448
496
M-1-80-i
4.098.166
497
M-1-80-ii
6.195.589
498
M-1-80-iii
499
M-4-10-i
2.207.041
500
M-4-10-ii
3.959.954
501
M-4-10-iii
FRAKTUR FEMUR BERAT
8.408.753
502
M-4-11-i
3.434.902
503
M-4-11-ii
7.880.177
504
M-4-11-iii
7.601.361
13.229.058
14.263.851
13.987.130
- 1258 No
Kode
INA-CBG
505
M-4-12-i
1.929.531
506
M-4-12-ii
3.510.780
507
M-4-12-iii
7.718.125
508
M-4-13-i
509
M-4-13-ii
510
M-4-13-iii
511
M-4-14-i
3.859.062
512
M-4-14-ii
6.739.094
513
M-4-14-iii
OSTEOMIELITIS BERAT
8.746.498
514
M-4-15-i
3.238.525
515
M-4-15-ii
4.018.091
516
M-4-15-iii
9.033.592
517
M-4-16-i
3.235.396
518
M-4-16-ii
4.727.926
519
M-4-16-iii
9.651.984
520
M-4-17-i
2.771.894
521
M-4-17-ii
3.635.178
522
M-4-17-iii
4.987.692
523
M-4-18-i
3.802.789
524
M-4-18-ii
4.683.034
525
M-4-18-iii
6.449.309
526
M-4-19-i
527
M-4-19-ii
528
M-4-19-iii
529
M-4-20-i
530
M-4-20-ii
531
M-4-20-iii
532
M-4-21-i
533
M-4-21-ii
534
M-4-21-iii
535
N-1-01-i
5.273.352
536
N-1-01-ii
7.132.089
537
N-1-01-iii
DESKRIPSI (INA-CBG)

RINGAN
SEDANG

ORTOPEDIK RINGAN
ORTOPEDIK SEDANG
ORTOPEDIK BERAT
(RINGAN)
(SEDANG)
(BERAT)
(RINGAN)
(SEDANG)
(BERAT)
Tarif
INA-CBG
4.791.369
5.363.967
14.253.121
2.827.425
4.526.027
7.222.171
2.107.874
2.894.297
3.207.563
2.019.861
3.387.672
6.994.550
15.122.150
- 1259 No
Kode
INA-CBG
538
N-1-11-i
9.097.364
539
N-1-11-ii
13.102.903
540
N-1-11-iii
20.793.974
541
N-1-12-i
542
N-1-12-ii

SEDANG
12.200.677
543
N-1-12-iii
22.236.495
544
N-1-20-i
7.100.475
545
N-1-20-ii
14.077.718
546
N-1-20-iii
16.103.634
547
N-1-30-i
8.447.269
548
N-1-30-ii
12.836.678
549
N-1-30-iii
14.148.902
550
N-1-40-i
7.611.816
551
N-1-40-ii
10.318.088
552
N-1-40-iii
12.000.234
553
N-4-10-i
2.968.881
554
N-4-10-ii
4.344.170
555
N-4-10-iii
8.560.961
556
N-4-11-i
2.484.473
557
N-4-11-ii
4.198.699
558
N-4-11-iii
4.804.683
559
N-4-12-i
2.402.370
560
N-4-12-ii
3.376.466
561
N-4-12-iii
5.306.895
562
N-4-13-i
BATU URIN RINGAN
3.424.153
563
N-4-13-ii
BATU URIN SEDANG
4.128.240
564
N-4-13-iii
BATU URIN BERAT
565
N-4-14-i
566
N-4-14-ii
567
N-4-14-iii
568
N-4-15-i
3.335.249
569
N-4-15-ii
4.577.000
570
N-4-15-iii
5.223.183
571
N-4-16-i
3.349.652
DESKRIPSI (INA-CBG)

Tarif
INA-CBG
3.898.870
10.166.724
1.688.158
2.599.552
4.215.644
- 1260 No
Kode
INA-CBG
572
N-4-16-ii
4.322.644
573
N-4-16-iii
8.621.464
574
O-6-10-i
4.166.347
575
O-6-10-ii
4.625.280
576
O-6-10-iii
5.699.912
577
O-6-11-i
578
O-6-11-ii
579
O-6-11-iii
580
O-6-12-i
581
O-6-12-ii
582
O-6-12-iii
583
O-6-13-i
2.061.289
584
O-6-13-ii
2.408.092
585
O-6-13-iii
2.994.782
586
P-8-01-i
587
P-8-01-ii
588
P-8-01-iii
589
P-8-02-i
590
P-8-02-ii
591
P-8-02-iii
592
P-8-03-i
593
P-8-03-ii
594
P-8-03-iii
595
P-8-04-i
596
P-8-04-ii
597
P-8-04-iii
598
P-8-05-i
599
P-8-05-ii
600
P-8-05-iii
601
P-8-06-i
602
P-8-06-ii
603
P-8-06-iii
DESKRIPSI (INA-CBG)

RINGAN
SEDANG
BERAT

RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
RINGAN
SEDANG
BERAT
Tarif
INA-CBG
2.630.270
4.285.481
7.262.561
2.908.872
3.493.548
4.389.143
48.969.190
60.591.713
71.117.686
79.009.456
90.631.979
103.553.516
3.249.058
4.839.352
8.794.927
39.029.993
50.652.515
72.622.957
21.223.244
30.081.088
44.320.445
2.972.034
7.797.740
14.295.857
- 1261 No
Kode
INA-CBG
604
P-8-07-i
605
P-8-07-ii
606
P-8-07-iii
607
P-8-08-i
608
P-8-08-ii
609
P-8-08-iii
610
P-8-10-i
611
P-8-10-ii
612
P-8-10-iii
613
P-8-11-i
2.712.866
614
P-8-11-ii
16.494.057
615
P-8-11-iii
16.839.610
616
P-8-12-i
3.655.032
617
P-8-12-ii
5.682.940
618
P-8-12-iii
6.704.668
619
P-8-13-i
1.889.118
620
P-8-13-ii
3.495.797
621
P-8-13-iii
5.228.339
622
P-8-14-i
623
P-8-14-ii
624
P-8-14-iii
625
P-8-15-i
2.595.722
626
P-8-15-ii
5.188.165
627
P-8-15-iii
6.094.303
628
P-8-16-i
2.349.742
629
P-8-16-ii
3.333.209
630
P-8-16-iii
4.326.669
631
P-8-17-i
1.548.009
632
P-8-17-ii
5.151.314
633
P-8-17-iii
634
S-4-10-i
1.929.531
635
S-4-10-ii
2.411.914
636
S-4-10-iii
3.135.074
DESKRIPSI (INA-CBG)
RINGAN
SEDANG
BERAT
PERNAFASAN RINGAN
PERNAFASAN SEDANG
PERNAFASAN BERAT
AKUT LAIN RINGAN
AKUT LAIN SEDANG
AKUT LAIN BERAT

RINGAN
SEDANG
BERAT
Tarif
INA-CBG
5.640.065
13.927.397
18.727.551
4.433.924
6.294.579
8.037.479
2.750.801
3.984.936
7.823.604
3.451.614
7.047.220
7.730.774
10.397.598
- 1262 No
Kode
INA-CBG
637
S-4-11-i
1.205.957
638
S-4-11-ii
1.929.531
639
S-4-11-iii
2.969.501
640
S-4-12-i
1.487.339
641
S-4-12-ii
2.034.296
642
S-4-12-iii
3.891.807
643
S-4-13-i
2.311.564
644
S-4-13-ii
3.807.926
645
S-4-13-iii
7.377.715
646
S-4-14-i
1.187.464
647
S-4-14-ii
2.522.572
648
S-4-14-iii
4.783.695
649
S-4-15-i
898.090
650
S-4-15-ii
1.695.002
651
S-4-15-iii
2.195.421
652
S-4-16-i
LUKA BAKAR RINGAN
3.686.874
653
S-4-16-ii
LUKA BAKAR SEDANG
6.414.754
654
S-4-16-iii
LUKA BAKAR BERAT
655
S-4-17-i
2.421.872
656
S-4-17-ii
2.820.520
657
S-4-17-iii
4.357.023
658
T-1-10-i
2.500.041
659
T-1-10-ii
3.357.385
660
T-1-10-iii
6.108.178
661
T-4-10-i
662
T-4-10-ii
663
T-4-10-iii
664
T-4-11-i
665
T-4-11-ii
666
T-4-11-iii
2.741.370
667
T-4-12-i
1.779.878
668
T-4-12-ii
2.652.064
669
T-4-12-iii
4.084.242
670
U-1-10-i
1.815.176
DESKRIPSI (INA-CBG)

RINGAN
SEDANG
Tarif
INA-CBG
11.454.540
821.201
1.565.027
2.275.124
1.081.497
1.701.969
- 1263 No
Kode
INA-CBG
671
U-1-10-ii
672
U-1-10-iii
673
U-1-11-i
7.797.740
674
U-1-11-ii
10.396.987
675
U-1-11-iii
23.496.064
676
U-1-12-i
6.409.794
677
U-1-12-ii
11.696.611
678
U-1-12-iii
15.188.270
679
U-1-13-i
5.198.494
680
U-1-13-ii
6.498.117
681
U-1-13-iii
682
U-1-14-i
3.858.245
683
U-1-14-ii
4.734.842
684
U-1-14-iii
5.610.921
685
U-1-15-i
2.266.094
686
U-1-15-ii
3.219.962
687
U-1-15-iii
6.345.064
688
U-1-20-i
5.861.399
689
U-1-20-ii
9.213.909
690
U-1-20-iii
691
U-1-30-i
5.028.058
692
U-1-30-ii
6.787.878
693
U-1-30-iii
694
U-4-10-i
4.680.282
695
U-4-10-ii
11.732.485
696
U-4-10-iii
17.115.140
697
U-4-11-i
2.172.018
698
U-4-11-ii
2.894.297
699
U-4-11-iii
5.384.177
700
U-4-12-i
1.929.531
701
U-4-12-ii
3.025.658
702
U-4-12-iii
4.810.659
703
U-4-13-i
704
U-4-13-ii
DESKRIPSI (INA-CBG)

RINGAN
SEDANG
Tarif
INA-CBG
3.703.978
15.994.524
11.309.974
19.135.576
10.396.987
1.929.531
2.203.771
- 1264 No
Kode
INA-CBG
705
U-4-13-iii
3.365.744
706
U-4-14-i
2.411.914
707
U-4-14-ii
2.894.297
708
U-4-14-iii
4.879.183
709
U-4-15-i
2.078.375
710
U-4-15-ii
2.737.136
711
U-4-15-iii
3.712.275
712
V-1-10-i
6.411.311
713
V-1-10-ii
7.277.402
714
V-1-10-iii
715
V-1-11-i
6.498.117
716
V-1-11-ii
7.252.008
717
V-1-11-iii
718
V-1-12-i
4.720.644
719
V-1-12-ii
14.410.509
720
V-1-12-iii
16.206.507
721
V-1-13-i
7.154.967
722
V-1-13-ii
13.596.490
723
V-1-13-iii
15.595.481
724
V-1-14-i
8.625.395
725
V-1-14-ii
12.544.899
726
V-1-14-iii
16.973.736
727
V-1-15-i
3.898.870
728
V-1-15-ii
6.084.443
729
V-1-15-iii
730
V-4-10-i
6.547.920
731
V-4-10-ii
8.457.421
732
V-4-10-iii
733
V-4-11-i
3.329.863
734
V-4-11-ii
4.865.462
735
V-4-11-iii
8.027.689
736
W-1-01-i
737
W-1-01-ii
738
W-1-01-iii
DESKRIPSI (INA-CBG)

RINGAN
SEDANG
BERAT
Tarif
INA-CBG
12.346.422
10.739.113
10.123.224
16.163.617
9.791.427
11.793.309
21.353.972
- 1265 No
Kode
INA-CBG
739
W-1-10-i
2.599.247
740
W-1-10-ii
5.088.844
741
W-1-10-iii
8.323.734
742
W-1-11-i
2.832.343
743
W-1-11-ii
5.198.494
744
W-1-11-iii
7.797.740
745
W-1-12-i
2.573.609
746
W-1-12-ii
2.926.144
747
W-1-12-iii
4.494.927
748
W-1-13-i
2.300.229
749
W-1-13-ii
2.497.386
750
W-1-13-iii
3.354.450
751
W-1-20-i
8.346.356
752
W-1-20-ii
10.396.987
753
W-1-20-iii
11.696.611
754
W-1-30-i
4.556.274
755
W-1-30-ii
6.498.117
756
W-1-30-iii
757
W-4-10-i
3.397.839
758
W-4-10-ii
4.592.560
759
W-4-10-iii
8.255.644
760
W-4-11-i
2.411.914
761
W-4-11-ii
4.047.649
762
W-4-11-iii
4.886.856
763
W-4-12-i
1.929.531
764
W-4-12-ii
3.297.843
765
W-4-12-iii
3.978.702
766
W-4-13-i
ABORTUS RINGAN
1.058.178
767
W-4-13-ii
ABORTUS SEDANG
1.447.148
768
W-4-13-iii
ABORTUS BERAT
1.929.531
769
W-4-14-i
1.447.148
770
W-4-14-ii
1.929.531
771
W-4-14-iii
2.342.043
772
W-4-15-i
1.447.148
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
19.326.050
- 1266 No
Kode
INA-CBG
773
W-4-15-ii
1.555.324
774
W-4-15-iii
1.967.761
775
W-4-16-i
1.628.532
776
W-4-16-ii
2.580.097
777
W-4-16-iii
3.288.278
778
W-4-17-i
1.447.148
779
W-4-17-ii
1.929.531
780
W-4-17-iii
3.650.289
781
Z-4-10-i
REHABILITASI RINGAN
3.344.180
782
Z-4-10-ii
REHABILITASI SEDANG
4.438.916
783
Z-4-10-iii
REHABILITASI BERAT
6.305.904
784
Z-4-11-i
3.887.352
785
Z-4-11-ii
4.679.513
786
Z-4-11-iii
7.315.775
787
Z-4-12-i
1.503.534
788
Z-4-12-ii
3.966.057
789
Z-4-12-iii
5.040.231
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
No
Kode
INA-CBG
B-2-10-0
B-2-11-0
1.037.943
B-2-12-0
1.930.192
B-2-13-0
1.595.117
B-2-14-0
1.332.582
B-3-10-0
B-3-11-0
B-3-12-0
214.059
C-3-10-0
583.922
10
C-3-11-0
923.495
11
C-3-12-0
209.354
12
C-3-13-0
203.297
13
C-3-14-0
1.730.674
14
C-3-15-0
1.586.232
15
C-3-16-0
359.719
16
C-3-17-0
238.627
17
C-3-18-0
105.797
18
C-3-19-0
149.618
19
C-3-20-0
20
C-3-21-0
170.741
21
C-3-22-0
749.646
22
C-3-23-0
121.426
23
D-2-10-0
1.028.740
24
D-2-11-0
PROSEDUR LIMPA
1.288.158
25
D-2-21-0
1.080.400
26
D-2-22-0
237.115
27
D-3-10-0
171.748
28
D-3-11-0
445.908
29
E-2-10-0
264.510
30
E-2-21-0
191.760
31
E-2-22-0

THYROGLOSSAL
191.760
32
E-3-10-0
223.005
33
F-3-10-0
TERAPI SHOCK
311.085
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
800.168
467.209
1.041.815
2.979.656
- 1268 No
Kode
INA-CBG
34
F-5-10-0
381.179
35
F-5-11-0
TERAPI KELOMPOK
251.353
36
F-5-12-0
321.648
37
F-5-13-0
272.415
38
F-5-14-0
182.754
39
F-5-15-0
171.447
40
F-5-16-0
178.578
41
G-2-10-0
PROSEDUR KRANIOTOMI
150.377
42
G-2-11-0
1.303.528
43
G-2-12-0
1.889.133
44
G-2-13-0
463.446
45
G-2-21-0
845.248
46
G-2-22-0
767.135
47
G-2-31-0
1.265.839
48
G-2-32-0
648.868
49
G-3-10-0
257.540
50
G-3-11-0
342.994
51
G-3-12-0
562.001
52
G-3-13-0
562.065
53
H-2-21-0
737.627
54
H-2-22-0
191.760
55
H-2-23-0
191.760
56
H-2-31-0
57
H-2-32-0
127.163
58
H-2-33-0
191.760
59
H-2-34-0
548.137
60
H-2-35-0
180.624
61
H-2-36-0
974.964
62
H-2-37-0
63
H-3-10-0
361.111
64
H-3-11-0
189.904
65
H-3-12-0
198.270
66
H-3-13-0
192.508
67
I-2-11-0
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
1.221.818
1.037.892
2.220.026
- 1269 No
Kode
INA-CBG
68
I-2-12-0
1.560.920
69
I-2-13-0
1.983.836
70
I-2-14-0
3.510.967
71
I-2-15-0
72
I-2-16-0

PENGGANTIAN ALAT
73
I-2-17-0
74
I-2-21-0
1.711.687
75
I-2-22-0
1.611.853
76
I-2-23-0
77
I-2-31-0
2.565.440
78
I-2-32-0
3.354.690
79
I-2-41-0
2.249.361
80
I-2-42-0

PERKUTAN LAIN
2.615.254
81
I-3-10-0
PROSEDUR RESUSITASI
331.983
82
I-3-11-0
175.220
83
I-3-12-0
84
I-3-13-0
334.453
85
I-3-14-0
214.373
86
I-3-15-0
189.904
87
J-2-10-0
88
J-2-21-0
189.533
89
J-2-22-0
955.128
90
J-2-31-0
91
J-2-32-0
921.937
92
J-3-10-0
191.760
93
J-3-11-0
541.881
94
J-3-12-0
209.354
95
J-3-13-0
308.117
96
J-3-14-0
327.100
97
J-3-15-0
286.841
98
J-3-16-0
327.100
99
J-3-17-0
191.760
100
K-2-10-0
551.952
101
K-2-11-0
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
211.143
2.217.620
731.086
329.861
1.018.313
1.175.764
1.238.886
1.178.642
- 1270 No
Kode
INA-CBG
102
K-2-12-0
103
K-2-13-0
104
K-2-14-0
191.760
105
K-2-21-0
191.760
106
K-2-22-0
107
K-2-31-0
828.712
108
K-2-32-0
191.760
109
K-2-41-0
912.843
110
K-2-42-0
260.811
111
K-2-51-0
604.905
112
K-2-52-0
329.861
113
K-2-53-0
191.760
114
K-3-10-0
364.907
115
K-3-11-0
219.380
116
K-3-12-0
222.479
117
K-3-13-0
191.760
118
K-3-14-0
513.922
119
K-3-15-0
248.180
120
K-3-16-0
328.854
121
L-2-21-0
1.130.613
122
L-2-22-0
724.715
123
L-2-31-0
327.100
124
L-2-32-0
329.861
125
L-2-41-0
987.730
126
L-2-42-0
221.532
127
L-2-51-0
1.478.786
128
L-2-52-0
1.131.320
129
L-2-53-0
191.760
130
L-3-10-0
260.811
131
L-3-11-0
253.265
132
L-3-12-0
192.886
133
M-2-10-0
1.512.906
134
M-2-21-0
1.354.912
135
M-2-22-0
329.861
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
904.760
1.472.546
2.464.577
- 1271 No
Kode
INA-CBG
136
M-2-31-0
PROSEDUR BUNION
822.973
137
M-2-32-0
260.811
138
M-2-41-0
260.811
139
M-2-42-0
140
M-2-51-0
191.760
141
M-2-52-0
191.760
142
M-2-61-0
PROSEDUR ARTROSKOPI
939.918
143
M-2-62-0
191.760
144
M-2-63-0
945.002
145
M-2-64-0
1.288.788
146
M-2-65-0
191.760
147
M-2-71-0
951.464
148
M-2-72-0
918.204
149
M-2-81-0
1.369.237
150
M-2-82-0
994.663
151
M-2-83-0
191.760
152
M-2-84-0
191.760
153
M-3-10-0
547.321
154
M-3-11-0
303.456
155
M-3-12-0
686.243
156
M-3-13-0
223.734
157
M-3-14-0
382.399
158
M-3-15-0
168.470
159
M-3-16-0
191.760
160
M-3-17-0
209.354
161
N-2-11-0
2.533.342
162
N-2-12-0
1.465.514
163
N-2-21-0
1.457.789
164
N-2-22-0
329.861
165
N-2-23-0
329.861
166
N-2-24-0
167
N-2-31-0
897.399
168
N-2-32-0
329.861
169
N-2-41-0
329.861
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
89.883
1.066.000
- 1272 No
Kode
INA-CBG
170
N-2-42-0
557.858
171
N-3-10-0
329.861
172
N-3-11-0
382.191
173
N-3-12-0
295.336
174
N-3-13-0
329.861
175
N-3-14-0
283.827
176
N-3-15-0
PROSEDUR DIALISIS
727.805
177
O-7-10-0
121.512
178
O-7-11-0
179
O-7-12-0
180
O-7-13-0
135.425
181
P-9-10-0

AKUT LAIN
180.624
182
P-9-11-0
180.624
183
P-9-12-0
180.624
184
P-9-13-0
180.624
185
P-9-14-0
180.624
186
P-9-15-0
115.133
187
P-9-16-0
180.624
188
P-9-17-0
179.847
189
Q-5-10-0
235.410
190
Q-5-11-0
176.434
191
Q-5-12-0
GIGI
155.504
192
Q-5-13-0
MEDICAL CHECK-UP
118.176
193
Q-5-14-0
130.032
194
Q-5-15-0
195
Q-5-16-0
VAKSINASI
196
Q-5-17-0
PASANG INFUS
197
Q-5-18-0
164.555
198
Q-5-19-0
183.963
199
Q-5-20-0
ABORSI MENGANCAM
123.304
200
Q-5-21-0
ABORSI
121.625
201
Q-5-22-0
130.032
202
Q-5-23-0
159.194
203
Q-5-24-0
108.727
DESKRIPSI (INA-CBG)

KURETASE
Tarif
INA-CBG
669.199
243.678
89.423
101.069
87.422
- 1273 No
Kode
INA-CBG
204
Q-5-25-0
169.558
205
Q-5-26-0
BRONKIAL AKUT
239.997
206
Q-5-27-0
170.794
207
Q-5-28-0
138.595
208
Q-5-29-0
392.385
209
Q-5-30-0
454.731
210
Q-5-31-0
FRAKTUR
162.230
211
Q-5-32-0
SALURAN KEMIH AKUT
187.899
212
Q-5-33-0
HEMATOLOGI AKUT
196.730
213
Q-5-34-0
INFEKSI VIRUS HIV
279.468
214
Q-5-35-0
INFEKSI AKUT
316.909
215
Q-5-36-0
369.061
216
Q-5-37-0
188.240
217
Q-5-38-0
PARU AKUT
251.024
218
Q-5-39-0
160.637
219
Q-5-40-0
157.611
220
Q-5-41-0
218.190
221
Q-5-42-0
171.069
222
Q-5-43-0
246.350
223
Q-5-44-0
201.056
224
T-2-10-0
104.284
225
U-2-10-0
1.391.789
226
U-2-11-0
1.654.296
227
U-2-12-0
182.016
228
U-2-13-0
238.627
229
U-2-14-0
443.261
230
U-2-15-0
251.851
231
U-2-21-0
293.367
232
U-2-22-0
566.809
233
U-2-23-0
742.703
234
U-2-24-0
625.938
235
U-2-25-0
238.627
236
U-2-31-0
191.760
237
U-2-32-0
238.627
DESKRIPSI (INA-CBG)
Tarif
INA-CBG
- 1274 No
Kode
INA-CBG
238
U-3-10-0
239
U-3-11-0
240
U-3-12-0
107.107
241
U-3-13-0

TENGGOROKAN
235.429
242
U-3-14-0
216.310
243
U-3-15-0
188.642
244
U-3-16-0
PROSEDUR PADA GIGI
212.754
245
V-2-10-0
246
V-2-11-0
PROSEDUR PADA PENIS
234.082
247
V-2-12-0
746.988
248
V-2-13-0
329.861
249
V-2-14-0
329.861
250
V-2-15-0
SIRKUMSISI/SUNAT
180.624
251
V-3-10-0
376.703
252
V-3-11-0
796.922
253
V-3-12-0
460.084
254
W-2-10-0
PROSEDUR ABORSI
168.470
255
W-2-11-0
430.547
256
W-2-12-0
796.922
257
W-2-13-0
127.812
258
W-2-21-0
1.602.025
259
W-2-22-0
168.470
260
W-2-23-0
562.193
261
W-2-31-0
1.845.507
262
W-2-32-0
1.294.338
263
W-2-33-0
550.111
264
W-2-34-0
187.102
265
W-3-10-0
454.731
266
W-3-11-0
363.499
267
W-3-12-0
168.470
268
Z-3-10-0
1.907.305
269
Z-3-11-0

SALURAN EMPEDU
1.457.789
270
Z-3-12-0
271
Z-3-13-0
DESKRIPSI (INA-CBG)
TENGGOROKAN
PROSEDUR KECIL LAIN-LAIN PADA TELINGA, HIDUNG, MULUT DAN
TENGGOROKAN
Tarif
INA-CBG
228.140
242.214
2.075.659
243.415
1.485.388
- 1275 No
Kode
INA-CBG
Tarif
INA-CBG
272
Z-3-14-0
DIAGNOSTIK TIDUR
293.707
273
Z-3-15-0
191.760
274
Z-3-16-0
615.492
275
Z-3-17-0
PENGOBATAN NUKLIR
258.397
276
Z-3-18-0
CT-SCAN KEPALA
248.961
277
Z-3-19-0
CT SCAN LAIN-LAIN
259.120
278
Z-3-20-0
176.233
279
Z-3-21-0
168.470
280
Z-3-22-0
189.935
281
Z-3-23-0
197.834
282
Z-3-24-0
388.704
283
Z-3-25-0
173.128
284
Z-3-26-0
195.669
285
Z-3-27-0
PERAWATAN LUKA
186.811
286
Z-3-28-0
IMAGING PAYUDARA
191.760
287
Z-3-29-0
IMAGING LAIN-LAIN
552.688
288
Z-3-30-0
FOTOTERAPI
DESKRIPSI (INA-CBG)
93.273
MENTERI KESEHATAN
REPUBLIK INDONESIA,
ttd
NAFSIAH MBOI

KMK No. 440 TTG Tarif RS Berdasarkan INA-CBG

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KMK No. 440 TTG Tarif RS Berdasarkan INA-CBG

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KEPUTUSAN MENTERI KESEHATAN REPUBLIK INDONESIA

: a. bahwa dalam rangka meningkatkan mutu pelayanan

bahwa berdasarkan pertimbangan sebagaimana

: 1. Undang-undang Nomor 36 tahun 2009 tentang

: KEPUTUSAN MENTERI KESEHATAN TENTANG TARIF

: Tarif Rumah Sakit berdasarkan Indonesia Case Based

: Tarif INA-CBG dalam setiap regional sebagaimana

-310. Tarif INA-CBG Rumah Sakit Khusus Stroke Nasional

: Daftar Tarif INA-CBG sebagaimana dimaksud pada

: Tarif INA-CBG sebagaimana dimaksud pada Diktum

: Tarif INA-CBG sebagaimana dimaksud pada Diktum

: Pada saat Keputusan ini mulai berlaku, Keputusan

: Keputusan ini berlaku mulai tanggal 01 Januari 2013.

TARIF INA-CBG RUMAH SAKIT UMUM DAN KHUSUS KELAS A

Tarif INA-CBG (Rp)

INFEKSI SESUDAH OPERASI & TRAUMA RINGAN

INFEKSI SESUDAH OPERASI & TRAUMA SEDANG

INFEKSI SESUDAH OPERASI & TRAUMA BERAT

INFEKSI NON BAKTERI RINGAN

INFEKSI NON BAKTERI SEDANG

INFEKSI NON BAKTERI BERAT

PENYAKIT INFEKSI BAKTERI DAN PARASIT

INFEKSI HIV RINGAN

INFEKSI HIV SEDANG

INFEKSI HIV BERAT

PROSEDUR PENCANGKOKAN HATI RINGAN

PROSEDUR PENCANGKOKAN HATI SEDANG

Tarif INA-CBG (Rp)

PROSEDUR PENCANGKOKAN HATI BERAT

PROSEDUR HATI DAN PANKREAS RINGAN

PROSEDUR HATI DAN PANKREAS SEDANG

PROSEDUR HATI DAN PANKREAS BERAT

PROSEDUR SALURAN EMPEDU KOMPLEK

SIROSIS DAN HEPATITIS ALKOHOLIK RINGAN

SIROSIS DAN HEPATITIS ALKOHOLIK SEDANG

SIROSIS DAN HEPATITIS ALKOHOLIK BERAT

TUMOR SISTEM HEPATOBILLIARI DAN

LEUKEMIA AKUT SEDANG

LEUKEMIA AKUT BERAT

Tarif INA-CBG (Rp)

LIMFOMA & LEUKEMIA NON AKUT RINGAN

LIMFOMA & LEUKEMIA NON AKUT SEDANG

LIMFOMA & LEUKEMIA NON AKUT BERAT

PROSEDUR LIMPA RINGAN

PROSEDUR LIMPA SEDANG

PROSEDUR LIMPA BERAT

GANGGUAN PEMBEKUAN DARAH RINGAN

GANGGUAN PEMBEKUAN DARAH SEDANG

GANGGUAN PEMBEKUAN DARAH BERAT

KRISIS ANEMIA SEL SICKLE RINGAN

KRISIS ANEMIA SEL SICKLE SEDANG

KRISIS ANEMIA SEL SICKLE BERAT

GANGGUAN SEL DARAH MERAH SELAIN

TUMOR MYELOPROLIFERATIF LAIN-LAIN

PROSEDUR PADA DARAH DAN ORGAN

Tarif INA-CBG (Rp)

PROSEDUR KELENJAR ADRENAL RINGAN

PROSEDUR KELENJAR ADRENAL SEDANG

GANGGUAN SEL DARAH MERAH SELAIN

PROSEDUR KELENJAR ADRENAL BERAT

GANGGUAN METABOLIK BAWAAN RINGAN

GANGGUAN METABOLIK BAWAAN SEDANG

GANGGUAN METABOLIK BAWAAN BERAT