11 10/16/2016 10/19/2016 17:34 111452 FAIZ FADILLAH SOQIB A-4-10-I 2.250.

200,00 C
1 10/25/2016 10/29/2016 21:11 54676 MUHAMMAD SAWALLUDIN A-4-13-I 1.943.000,00 C
17 10/6/2016 10/9/2016 18:30 127453 ADELINO ZAFIR A-4-13-I 2.331.600,00 C
5 10/19/2016 10/19/2016 14:59 115156 RATU DEWI SUTI K, SE A-4-13-I 2.720.200,00 C
9 9/26/2016 9/29/2016 19:22 125474 ZHAFIRA KHAIRINNISWA A-4-13-I 2.720.200,00 C
11 9/20/2016 9/21/2016 15:06 127400 FABRILYAS HANIF PRANA A-4-13-I 2.720.200,00 C
18 10/1/2016 10/9/2016 12:57 92404 MUHAMMAD ILHAM AR ROYYAA-4-13-III 3.398.900,00 C
13 9/5/2016 9/10/2016 18:35 34436 SALMA NABILAH A-4-13-III 3.965.400,00 C
4 10/22/2016 10/26/2016 14:24 127491 DEDEH SANIMAH A-4-14-I 2.774.500,00 C
8 10/14/2016 10/18/2016 22:49 127470 NIASARI NASTITI A-4-14-I 2.774.500,00 C
1 10/26/2016 10/30/2016 23:13 127518 AL ZAFRAN SYAFIQ MULYANA A-4-14-I 3.884.300,00 C
12 9/12/2016 9/17/2016 16:13 127390 CATHARINA KEISHA VALLERINA A-4-14-I 3.884.300,00 C
7 10/18/2016 10/21/2016 8:58 127482 ADAM SYABRI E-4-11-I 1.652.700,00 C
14 10/15/2016 10/17/2016 20:47 79646 ATILLA AKBAR RAMADHAN E-4-11-I 1.983.200,00 C
9 10/7/2016 10/13/2016 20:17 127454 ALIF SEBASTIAN YUSUF J-4-16-I 3.475.100,00 C
2 10/27/2016 10/30/2016 1:56 127519 AULIA RAHMA SHAFIYA J-4-16-II 5.860.100,00 C
10 10/6/2016 10/8/2016 13:37 127451 AULIA MAHARDIKA K-4-17-I 2.355.800,00 C
5 10/26/2016 10/28/2016 11:38 127511 MUHAMMAD JAKA AR-RAZIE K-4-17-I 2.423.100,00 C
10 10/22/2016 10/23/2016 14:31 101010 JANNETE GRATIA LASMARIA TO K-4-17-I 2.423.100,00 C
2 10/28/2016 10/30/2016 20:45 123162 NURAINI PUTRI PARWIDI K-4-17-I 2.827.100,00 C
8 10/10/2016 10/11/2016 11:39 86161 FAUZAH K-4-17-I 2.827.100,00 C
10 9/26/2016 9/28/2016 11:59 99799 ANABELL GISELLA TAMBA K-4-17-I 2.827.100,00 C
3 10/24/2016 10/27/2016 15:47 12790 SILVY AL FIYANI K-4-18-I 2.779.600,00 C
22 9/25/2016 9/27/2016 14:33 123134 MUHAMMAD RAMZI SYUKUR K-4-18-I 3.335.500,00 C
20 10/1/2016 10/4/2016 16:39 25290 PURWATI SARI N-4-13-II 2.957.900,00 C
2 10/25/2016 10/29/2016 15:28 127508 PUTRI AMELIA O-6-10-I 4.022.100,00 C
4 10/26/2016 10/29/2016 10:36 127513 YULI MAYA SARI O-6-10-I 4.826.600,00 C
7 10/22/2016 10/25/2016 21:13 127494 KARUNIA PUSPITA SARI O-6-10-I 4.826.600,00 C
9 10/21/2016 10/23/2016 17:40 127488 SITI ROHANA O-6-10-I 4.826.600,00 C
13 10/15/2016 10/18/2016 9:16 127439 SAHLAWATI NASUTION O-6-10-I 4.826.600,00 C
19 10/4/2016 10/6/2016 20:51 127445 YULPA O-6-10-I 4.826.600,00 C
21 9/27/2016 9/30/2016 10:10 127407 INTAN DWI ASTUTI O-6-10-I 4.826.600,00 C
3 10/26/2016 10/29/2016 12:31 127504 ROSYATI O-6-10-I 5.631.000,00 C
6 10/8/2016 10/11/2016 13:19 127457 RINING SUSTIKA O-6-10-I 5.631.000,00 C
1 10/28/2016 10/31/2016 8:42 127521 RIA PURWANI YULIASTUTI O-6-10-II 5.326.100,00 C
4 10/18/2016 10/21/2016 18:55 121252 IKA BRAHMAYANTI O-6-10-II 6.213.800,00 C
6 10/24/2016 10/24/2016 20:03 127500 DINA MARDIANA O-6-13-I 2.013.600,00 C
15 10/12/2016 10/14/2016 20:23 127468 SHAFA SHAKILA ALFATHUNISSA P-8-03-I 2.552.100,00 C
7 10/8/2016 10/11/2016 12:32 127464 BAYI NY RINING SUSTIKA P-8-03-I 2.977.500,00 C
3 10/26/2016 10/29/2016 15:18 127514 BAYI NY YULI MAYA SARI P-8-17-I 1.995.800,00 C
8 10/22/2016 10/25/2016 12:02 127495 BAYI NY KARUNIA PUSPITA SARI P-8-17-I 1.995.800,00 C
12 10/15/2016 10/18/2016 14:22 127462 BAYI NY SAHLAWATI NASUTION P-8-17-I 1.995.800,00 C
6 10/24/2016 10/25/2016 21:27 127506 SRI WAHYUNI W-1-11-I 3.279.100,00 C
16 10/12/2016 10/13/2016 8:49 67883 NURFARA DISIL UMMAH W-1-11-I 3.279.100,00 C
5 10/24/2016 10/25/2016 12:21 127505 TIANAS LUMBAN TORUAN W-4-13-I 849.400,00 C
 3.034.107,00 Inap Dwi Ariyant
2.634.418,00 Inap Dwi Ariyant
2.292.614,00 Inap Grouper Administrator
2.153.000,00 Inap Dwi Ariyant
2.866.681,00 Inap Grouper Administrator
1.766.254,00 Inap Grouper Administrator
12.340.000,00 Inap Grouper Administrator
4.786.500,00 Inap Dwi Ariyant
2.279.397,00 Inap Dwi Ariyant
2.507.189,00 Inap Dwi Ariyant
3.357.518,00 Inap Grouper Administrator
4.279.500,00 Inap Dwi Ariyant
2.271.824,00 Inap Dwi Ariyant
1.892.256,00 Inap Dwi Ariyant
3.351.537,00 Inap Dwi Ariyant
2.342.703,00 Inap Dwi Ariyant
1.895.000,00 Inap Grouper Administrator
1.982.822,00 Inap Dwi Ariyant
1.242.911,00 Inap Dwi Ariyant
2.137.627,00 Inap Dwi Ariyant
1.693.925,00 Inap Dwi Ariyant
1.838.513,00 Inap Dwi Ariyant
2.056.835,00 Inap Dwi Ariyant
1.651.826,00 Inap Grouper Administrator
2.201.676,00 Inap Dwi Ariyant
8.717.972,00 Inap Grouper Administrator
10.207.651,00 Inap Dwi Ariyant
12.359.051,00 Inap Grouper Administrator
12.256.819,00 Inap Dwi Ariyant
10.403.397,00 Inap Grouper Administrator
10.907.537,00 Inap Dwi Ariyant
9.969.661,00 Inap Dwi Ariyant
12.199.176,00 Inap Dwi Ariyant
12.939.120,00 Inap Dwi Ariyant
9.988.105,00 Inap Dwi Ariyant
12.646.155,00 Inap Dwi Ariyant
4.172.206,00 Inap Grouper Administrator
2.727.980,00 Inap Dwi Ariyant
1.959.835,00 Inap Dwi Ariyant
1.908.378,00 Inap Dwi Ariyant
2.023.086,00 Inap Grouper Administrator
1.879.063,00 Inap Grouper Administrator
3.519.720,00 Inap Grouper Administrator
4.775.410,00 Inap Dwi Ariyant
2.787.123,00 Inap Dwi Ariyant
 PERBANDING

NO DIAGNOSA KODE INA CBG PMK 59 PMK 52

KELAS 3
1 SEPSIS A-4-10-I Rp 1,477,700.00 Rp 1,775,900.00
VIRAL INFECTION
MORBILI
A-4-13-1 Rp 1,251,000.00 Rp 1,078,500.00
DHF
2
DEMAM DENGEU
A-4-13-II Rp 1,505,800.00 Rp 1,450,500.00
A-4-13-III Rp 1,822,800.00 Rp 1,740,700.00
INFEKSI BAKTERI
3 A-4-14-I Rp 2,522,200.00 Rp 2,155,300.00
THYPOID FEVER
4 HYPOVOLUMI DAN GGN ELEKTROLIT E-4-11-I Rp 1,799,100.00 Rp 2,070,300.00
5 PNEUMONIA J-4-16-I Rp 3,159,200.00 Rp 3,424,000.00
J-4-16-II Rp 4,439,400.00 Rp 4,811,600.00
6 DIARE K-4-17-I Rp 1,768,100.00 Rp 1,112,000.00
7 DYSPEPSIA K-4-18-I Rp 2,526,900.00 Rp 1,116,500.00
8 CAESAR O-6-10-I Rp 3,666,500.00 Rp 4,422,400.00
O-6-10-II Rp 4,034,900.00 Rp 4,678,500.00
9 BAYI LAHIR SC BB >2499 P-8-17-I Rp 1,512,000.00 Rp 3,270,500.00
10 KURETASE W-1-11-I Rp 2,484,200.00 Rp 1,563,500.00
11 ABORTUS W-4-13-I Rp 710,800.00 Rp 871,400.00
 PERBANDINGAN TARIF KELAS D

PMK 64 PMK 59 PMK 52

SELISIH SELISIH
ELAS 3 KELAS 2
Rp 298,200.00 Rp 1,773,300.00 Rp 2,131,100.00 Rp 357,800.00

Rp (172,500.00) Rp 1,501,200.00 Rp 1,294,200.00 Rp (207,000.00)

Rp (55,300.00) Rp 1,807,000.00 Rp 1,740,700.00 Rp (66,300.00)

Rp (82,100.00) Rp 2,187,400.00 Rp 2,088,800.00 Rp (98,600.00)
Rp (366,900.00) Rp 3,026,700.00 Rp 2,586,300.00 Rp (440,400.00)

Rp 271,200.00 Rp 2,159,000.00 Rp 2,484,300.00 Rp 325,300.00

Rp 264,800.00 Rp 3,791,000.00 Rp 4,108,800.00 Rp 317,800.00
Rp 372,200.00 Rp 5,327,300.00 Rp 5,773,900.00 Rp 446,600.00
Rp (656,100.00) Rp 2,121,700.00 Rp 1,334,400.00 Rp (787,300.00)
Rp (1,410,400.00) Rp 3,032,300.00 Rp 1,339,800.00 Rp (1,692,500.00)
Rp 755,900.00 Rp 4,387,800.00 Rp 5,306,800.00 Rp 919,000.00
Rp 643,600.00 Rp 4,841,900.00 Rp 5,614,200.00 Rp 772,300.00
Rp 1,758,500.00 Rp 1,814,400.00 Rp 3,924,500.00 Rp 2,110,100.00
Rp (920,700.00) Rp 2,981,000.00 Rp 1,876,200.00 Rp (1,104,800.00)
Rp 160,600.00 Rp 853,000.00 Rp 1,045,700.00 Rp 192,700.00
PMK 59 PMK 52
SELISIH
KELAS 1
Rp 2,068,800.00 Rp 2,486,200.00 Rp 417,400.00

Rp 1,751,400.00 Rp 1,509,900.00 Rp (241,500.00)

Rp 2,108,100.00 Rp 2,030,800.00 Rp (77,300.00)

Rp 2,551,900.00 Rp 2,437,000.00 Rp (114,900.00)
Rp 3,531,100.00 Rp 3,017,400.00 Rp (513,700.00)

Rp 2,518,800.00 Rp 2,898,400.00 Rp 2,193,500.00

Rp 4,422,800.00 Rp 4,793,600.00 Rp 370,800.00
Rp 6,215,200.00 Rp 6,736,200.00 Rp 521,000.00
Rp 2,475,300.00 Rp 1,556,800.00 Rp (918,500.00)
Rp 3,537,700.00 Rp 1,563,100.00 Rp (1,974,600.00)
Rp 5,119,100.00 Rp 6,191,300.00 Rp 1,072,200.00
Rp 5,648,900.00 Rp 6,549,900.00 Rp 901,000.00
Rp 2,116,700.00 Rp 4,578,600.00 Rp 2,461,900.00
Rp 3,477,800.00 Rp 2,188,900.00 Rp (1,288,900.00)
Rp 995,100.00 Rp 1,220,000.00 Rp 224,900.00
NO DIAGNOSA KODE INA CBG PMK 59 PMK 52 PMK 64
SELISIH 52 -64
KELAS 3
1 SEPSIS A-4-10-I Rp 1,875,200.00 Rp 2,137,400.00 Rp 1,938,700.00 Rp (198,700.00)
VIRAL INFECTION
MORBILI
A-4-13-1 Rp 1,943,000.00 Rp 1,554,500.00 Rp 1,554,400.00 Rp (100.00)
DHF
2
DEMAM DENGEU
A-4-13-II Rp 2,326,600.00 Rp 2,341,700.00 Rp 2,341,700.00 Rp -
A-4-13-III Rp 2,832,400.00 Rp 2,810,000.00 Rp 2,810,100.00 Rp 100.00
INFEKSI BAKTERI Rp -
3 A-4-14-I Rp 2,774,500.00 Rp 2,155,300.00 Rp 2,155,300.00
THYPOID FEVER
4 HYPOVOLUMI DAN GGN ELEKTROLIT E-4-11-I Rp 1,662,700.00 Rp 2,491,700.00 Rp 2,260,000.00 Rp (231,700.00)
5 PNEUMONIA J-4-16-I Rp 3,475,100.00 Rp 3,784,400.00 Rp 3,432,600.00 Rp (351,800.00)
J-4-16-II Rp 4,883,400.00 Rp 5,318,100.00 Rp 4,823,600.00 Rp (494,500.00)
6 DIARE K-4-17-I Rp 2,355,800.00 Rp 1,448,400.00 Rp 1,448,400.00 Rp -
7 DYSPEPSIA K-4-18-I Rp 2,779,600.00 Rp 1,279,900.00 Rp 1,279,900.00 Rp -
8 CAESAR O-6-10-I Rp 4,022,100.00 Rp 4,975,200.00 Rp 4,975,200.00 Rp -
O-6-10-II Rp 4,438,400.00 Rp 5,255,100.00 Rp 5,255,100.00 Rp -
9 BAYI LAHIR SC BB >2499 P-8-17-I Rp 1,663,200.00 Rp 3,777,400.00 Rp 3,426,200.00 Rp (351,200.00)
10 KURETASE W-1-11-I Rp 2,732,600.00 Rp 1,881,800.00 Rp 1,706,800.00 Rp (175,000.00)
11 ABORTUS W-4-13-I Rp 849,400.00 Rp 1,048,800.00 Rp 951,300.00 Rp (97,500.00)
 PMK 59 PMK 52 PMK 64 SELISIH 52-64 PMK 59
SELISIH 59 KE 52 SELISIH 59-52
KELAS 2 KELAS 1
Rp 262,200.00 Rp 2,250,200.00 Rp 2,564,900.00 Rp 2,326,400.00 Rp (238,500.00) Rp 314,700.00 Rp 2,625,200.00
Rp (100.00)

Rp (388,500.00) Rp 2,331,600.00 Rp 1,865,400.00 Rp 1,865,300.00 Rp (466,200.00) Rp 2,720,200.00

Rp 15,100.00 Rp 2,791,900.00 Rp 2,810,000.00 Rp 2,810,100.00 Rp 100.00 Rp 18,100.00 Rp 3,257,200.00

Rp (22,400.00) Rp 3,398,900.00 Rp 3,372,100.00 Rp 3,372,100.00 Rp - Rp (26,800.00) Rp 3,966,400.00
Rp 100.00
Rp (619,200.00) Rp 3,329,400.00 Rp 2,586,300.00 Rp 2,586,400.00 Rp (743,100.00) Rp 3,884,300.00

Rp 829,000.00 Rp 1,983,200.00 Rp 2,990,000.00 Rp 2,712,100.00 Rp (277,900.00) Rp 1,006,800.00 Rp 2,313,800.00

Rp 309,300.00 Rp 4,170,100.00 Rp 4,541,300.00 Rp 4,119,100.00 Rp (422,200.00) Rp 371,200.00 Rp 4,866,100.00
Rp 434,700.00 Rp 5,860,100.00 Rp 6,381,700.00 Rp 5,788,400.00 Rp (593,300.00) Rp 521,600.00 Rp 6,836,700.00
Rp (907,400.00) Rp 2,423,100.00 Rp 1,738,100.00 Rp 1,738,100.00 Rp - Rp (685,000.00) Rp 2,827,100.00
Rp (1,499,700.00) Rp 3,335,500.00 Rp 1,535,800.00 Rp 1,535,900.00 Rp 100.00 Rp (1,799,700.00) Rp 3,891,400.00
Rp 953,100.00 Rp 4,826,600.00 Rp 5,970,200.00 Rp 5,970,200.00 Rp - Rp 1,143,600.00 Rp 5,631,000.00
Rp 816,700.00 Rp 5,326,100.00 Rp 6,306,100.00 Rp 6,306,100.00 Rp - Rp 980,000.00 Rp 6,213,800.00
Rp 2,114,200.00 Rp 1,995,800.00 Rp 4,532,900.00 Rp 4,111,400.00 Rp (421,500.00) Rp 2,537,100.00 Rp 2,328,400.00
Rp (850,800.00) Rp 3,279,100.00 Rp 2,258,200.00 Rp 2,048,200.00 Rp (210,000.00) Rp (1,020,900.00) Rp 3,825,600.00
Rp 199,400.00 Rp 1,019,300.00 Rp 1,258,600.00 Rp 1,141,600.00 Rp (117,000.00) Rp 239,300.00 Rp 1,189,200.00
 PMK 52 PMK 64 SELISIH 52-64
SELISIH
KELAS 1
Rp 2,992,400.00 Rp 2,714,200.00 Rp (278,200.00) Rp 367,200.00
Rp (100.00)

Rp 2,176,300.00 Rp 2,176,200.00 Rp (543,900.00)

Rp 3,278,400.00 Rp 3,278,400.00 Rp - Rp 21,200.00

Rp 3,934,100.00 Rp 3,934,100.00 Rp - Rp (32,300.00)
Rp 3,017,400.00 Rp -
Rp 3,017,400.00 Rp (866,900.00)

Rp 3,488,400.00 Rp 3,164,100.00 Rp (324,300.00) Rp 1,307,000.00

Rp 5,298,200.00 Rp 4,805,600.00 Rp (492,600.00) Rp 432,100.00
Rp 7,445,300.00 Rp 6,753,100.00 Rp (692,200.00) Rp 608,600.00
Rp 2,027,700.00 Rp 2,027,800.00 Rp 100.00 Rp (799,400.00)
Rp 1,791,800.00 Rp 1,791,800.00 Rp - Rp (2,099,600.00)
Rp 6,965,200.00 Rp 6,965,200.00 Rp - Rp 1,334,200.00
Rp 7,357,100.00 Rp 7,357,100.00 Rp - Rp 1,143,300.00
Rp 5,288,300.00 Rp 4,796,700.00 Rp (491,600.00) Rp 2,959,900.00
Rp 2,634,500.00 Rp 2,389,600.00 Rp (244,900.00) Rp (1,191,100.00)
Rp 1,468,400.00 Rp 1,331,800.00 Rp (136,600.00) Rp 279,200.00
PAKET SC RS SELASIH

NO ITEM UNIT COST BIAYA TOTAL

1 INACBGS
KELAS 3 Rp 4,975,200.00
KELAS 2 Rp 5,970,200.00
KELAS 1 Rp 6,965,200.00