No

1
2
1.1
1.2
1.3
1.4
1.5
1.6
2.1
2.2
2.3
2.4
2.5
3
3.1
3.2
3.3
3.4
3.5
3.6

No
1
2
3
3.1
3.2
3.3
3.4
3.5
3.6
3.7
4
5
5.1
5.2
5.3
5.4
5.5
6
7
2.1
2.2
2.3
2.4
2.5
6.1
8
 Deskripsi Tindakan
Limited eye examination (kurang dari 4 tindakan)
Comprehensive eye examination
SLITLAMP SAJA
SLITLAMP + INJEKSI ( CEFO/DEXA/KALMET)
SLITLAMP + ARK
SLITLAMP + FUNDUSKOPI
SLITLAMP + FLUORESCEIN TEST
SLITLAMP + ARK + FUNDUSKOPI + FLUORESCEIN TEST
SLITLAMP + ARK + FUNDUSKOPI + FLUORESCEIN TEST + NCT
NCT SAJA
NCT + FUNDUSKOPI + FLUORESCEIN TEST
NCT + FLUORESCEIN TEST
NCT + SLIT LAMP
INDIREK OFTALMOSKOP SAJA
INDIREK OFTALMOSKOP + SLIT LAMP
INDIREK OFTALMOSKOP + FUNDUSKOPI
INDIREK OFTALMOSKOP + FLUORESCEIN TEST
INDIREK OFTALMOSKOP + SLIT LAMP + FUNDUSKOPI + FLUORESCEIN TEST
INDIREK OFTALMOSKOP + NCT
INDIREK OFTALMOSKOP + SLIT LAMP + FUNDUSKOPI + FLUORESCEIN TEST + NCT

Deskripsi Tindakan PENUNJANG

HUMPHREY SAJA
USG SAJA
BIOMETRI SAJA
BIOMETRI + SLIT LAMP
BIOMETRI + FUNDUSKOPI
BIOMETRI + FLUORESCEIN TEST
BIOMETRI + SLIT LAMP + FUNDUSKOPI + FLUORESCEIN TEST
BIOMETRI + SLIT LAMP + FUNDUSKOPI + FLUORESCEIN TEST + NCT
BIOMETRI + SLIT LAMP + FUNDUSKOPI + FLUORESCEIN TEST + INDIREK OFTALMOSKOP
BIOMETRI + SLIT LAMP + FUNDUSKOPI + FLUORESCEIN TEST + NCT + INDIREK OFTALMOSKOP
TMG/GONIOSCOPY SAJA
GONIOS + SLIT LAMP
GONIOS + FUNDUSKOPI
GONIOS + FLUORESCEIN TEST
GONIOS + NCT
GONIOS + INDIREK OFTALMOSKOP
GONIOS + SLIT LAMP + FUNDUSKOPI + FLUORESCEIN TEST + NCT + INDIREK OFTALMOSKOP
FOTO FUNDUS SAJA
OCT SAJA
USG + BIOMETRI
USG + NCT
USG + NCT + BIOMETRI
USG + NCT + BIOMETRI + FOTO FUNDUS
USG + NCT + BIOMETRI + FOTO FUNDUS + OCT
FOTO FUNDUS + OCT
IRIGASI
 KODE TARIF INACBG
95.01 Rp 185,000
95.02 Rp 210,600
95.01 Rp 185,000
95.02 Rp 210,600
95.01 Rp 185,000
95.01 Rp 185,000
95.01 Rp 185,000
95.01 Rp 185,000
95.02 Rp 210,600
95.02 Rp 210,600
95.02 Rp 210,600
95.02 Rp 210,600
95.02 Rp 210,600
16.21 Rp 210,600
16.21 Rp 210,600
16.21 Rp 210,600
16.21 Rp 210,600
16.21 Rp 210,600
95.02 Rp 210,600
95.02 Rp 210,600

KODE TARIF INACBG

95.05 Rp 210,600
95.13 Rp 237,300
95.09 Rp 185,000
95.09 Rp 185,000
95.09 Rp 185,000
95.09 Rp 185,000
95.09 Rp 185,000
95.02 Rp 210,600
95.02 Rp 210,600
95.02 Rp 210,600
12.29 Rp 254,500
12.29 Rp 254,500
12.29 Rp 254,500
12.29 Rp 254,500
12.29 Rp 254,500
12.29 Rp 254,500
12.29 Rp 254,500
95.11 Rp 237,300
95.16 Rp 237,300
95.13 Rp 237,300
95.13 Rp 237,300
95.13 Rp 237,300
95.13 + 95.11 Rp 237,300
95.13 + 95.11 + 95.16 Rp 237,300
95.11 + 95.16 Rp 237,300
96.51 Rp 210,600
No Deskripsi Tindakan KODE Tindakan Tarif INA-CBG'S
1 YAG LASER 13.64 Rp 469,900
2 LASER RETINA DIABETIC (PRP) / FOTOKOAGULASI 14.24 Rp 469,900
3 LASER BARGE 14.34 Rp 763,900
4 LASER LPI 12.12 Rp 254,200
5 LASER SUTURE LYSIS (PASCA TRABEK) 12.79 Rp 1,960,000
No Deskripsi Tindakan KODE Tindakan Tarif INA-CBG'S
1 AJ KORNEA/AJ KULIT 11.52 Rp 254,500
2 EPILASI 08.93 Rp 502,200
3 EXT. Tumor 08.23/08.24 Rp 878,900
4 Insisi Hordeolum 08.09 Rp 252,000
5 EXT. CHALAZION 08.21 Rp 502,200
6 EXT. PTG (Pterygium) 11.39 Rp 878,900
7 (ALR) Reconstruction of eyelid, not otherwise specified 08.44 Rp 878,900
8 TRAUMA/RUPTURE/SOBEK PADA EYELID 08.72 Rp 1,883,400
9 EXT. LITHIASIS 08.20 Rp 502,200
10 REMOVAL VITREOUS 14.71 Rp 1,470,400
11 EXT. Corpus/gram 98.21 Rp 252,700
12 injeksi TCA subtenion 10.91 Rp 252,700
13 injeksi OF VITREOUS 14.75 Rp 1,470,000
14 EVISERASI 16.39 Rp 878,900
15 PASANG PROTESE 16.61 Rp 878,900
16 PARASINTESA 12.91 Rp 1,307,000
No. Deskripsi Tindakan KODE Tindakan Tarif INA-CBG'S
1 REPAIR IOL 11.52 Rp 254,500
2 REPOSISI IOL (TANPA GANTI IOL) 13.90 Rp 254,500
3 REMOVAL IOL 13.8 Rp 254,500
4 SECONDARY IMPLANT IOL 13.72 Rp 3,307,500
5 EXCHANGE IOL /REPOSISI IOL (DENGAN GANTI IOL) 13.70 Rp 3,307,500
6 SISA KORTEK (ASPIRASI) 13.3 Rp 3,307,500
7 TRABEKULEKTOMI 12.54 Rp 1,960,000
8 ANTERIOR SINEKIOLISIS 12.32 Rp 1,307,000
9 POSTERIOR SINEKIOLISIS 12.33 Rp 1,307,000
10 OPERASI IRIDECTOMY 12.65 Rp 1,960,600
11 GONIOSINEKIOLISIS (MENGGUNAKAN UDARA/CAIRAN) 12.31 Rp 1,307,000
12 PHACO 13.41 Rp 3,307,500
13 SICS 13.2 Rp 3,307,500
14 INSERT IOL 13.71
15 PHACO+INSERT IOL 13.41+13.71 Rp 6,615,000
16 SICS+INSERT IOL 13.2+13.71 Rp 3,307,500
17 PHACO+INSERT IOL+TRABEK 13.41+13.71 Rp 6,615,000
18 SICS+INSERT IOL+TRABEK 13.2+13.71 Rp 3,307,500