sheet1 -1

LAPORAN REKAP KLAIM - R

Pasien Rawat Inap dan Rawat Jalan, Per
Filter: / Kelas Rawat = Semua / Severity = Semua / Cara
No. Tgl. Masuk Tgl. Pulang No. RM
1 30 Mei 2023 1 Jun 2023 00089732
2 29 Mei 2023 1 Jun 2023 00106482
3 29 Mei 2023 1 Jun 2023 00073198
4 30 Mei 2023 1 Jun 2023 00090892
5 30 Mei 2023 1 Jun 2023 00021878
6 29 Mei 2023 1 Jun 2023 00102000
7 29 Mei 2023 1 Jun 2023 00075930
8 30 Mei 2023 1 Jun 2023 00086833
9 29 Mei 2023 1 Jun 2023 00097152
10 29 Mei 2023 2 Jun 2023 00005311
11 30 Mei 2023 2 Jun 2023 00029553
12 30 Mei 2023 2 Jun 2023 00106513
13 29 Mei 2023 2 Jun 2023 00106654
14 26 Mei 2023 2 Jun 2023 00096184
15 1 Jun 2023 2 Jun 2023 00089670
16 30 Mei 2023 2 Jun 2023 00104675
17 31 Mei 2023 2 Jun 2023 00106738
18 29 Mei 2023 2 Jun 2023 00077819
19 31 Mei 2023 2 Jun 2023 00106266
20 30 Mei 2023 2 Jun 2023 00104984
21 1 Jun 2023 3 Jun 2023 00106762
22 2 Jun 2023 3 Jun 2023 00018463
23 31 Mei 2023 3 Jun 2023 00066761
24 31 Mei 2023 3 Jun 2023 00050483
25 30 Mei 2023 3 Jun 2023 00099518
26 31 Mei 2023 3 Jun 2023 00000359
27 1 Jun 2023 3 Jun 2023 00106763
28 30 Mei 2023 3 Jun 2023 00047213
29 30 Mei 2023 3 Jun 2023 00106648
30 30 Mei 2023 3 Jun 2023 00106712
31 1 Jun 2023 3 Jun 2023 00106769
32 1 Jun 2023 3 Jun 2023 00106761
33 1 Jun 2023 3 Jun 2023 00106749
34 26 Mei 2023 3 Jun 2023 00105231
35 2 Jun 2023 4 Jun 2023 00093154
36 2 Jun 2023 4 Jun 2023 00042744
37 2 Jun 2023 4 Jun 2023 00093655
38 3 Jun 2023 4 Jun 2023 00106794
39 1 Jun 2023 4 Jun 2023 00039292

Page 1
 sheet1 -1

40 31 Mei 2023 4 Jun 2023 00073200

41 31 Mei 2023 4 Jun 2023 00046864
42 3 Jun 2023 5 Jun 2023 00101638
43 3 Jun 2023 5 Jun 2023 00103291
44 2 Jun 2023 5 Jun 2023 00106786
45 2 Jun 2023 5 Jun 2023 00099542
46 3 Jun 2023 5 Jun 2023 00106791
47 2 Jun 2023 6 Jun 2023 00094959
48 3 Jun 2023 6 Jun 2023 00042202
49 3 Jun 2023 6 Jun 2023 00106800
50 4 Jun 2023 7 Jun 2023 00070274
51 2 Jun 2023 7 Jun 2023 00043963
52 5 Jun 2023 7 Jun 2023 00106807
53 5 Jun 2023 7 Jun 2023 00106229
54 6 Jun 2023 7 Jun 2023 00001586
55 3 Jun 2023 7 Jun 2023 00064312
56 4 Jun 2023 7 Jun 2023 00106790
57 5 Jun 2023 7 Jun 2023 00106839
58 5 Jun 2023 7 Jun 2023 00106817
59 30 Mei 2023 7 Jun 2023 00012711
60 5 Jun 2023 8 Jun 2023 00079438
61 5 Jun 2023 8 Jun 2023 00017891
62 5 Jun 2023 8 Jun 2023 00032777
63 7 Jun 2023 8 Jun 2023 00106810
64 5 Jun 2023 8 Jun 2023 00046828
65 6 Jun 2023 8 Jun 2023 00005532
66 6 Jun 2023 8 Jun 2023 00106808
67 6 Jun 2023 8 Jun 2023 00093048
68 6 Jun 2023 8 Jun 2023 00106885
69 4 Jun 2023 8 Jun 2023 00101416
70 5 Jun 2023 8 Jun 2023 00056212
71 7 Jun 2023 8 Jun 2023 00106666
72 5 Jun 2023 9 Jun 2023 00106818
73 7 Jun 2023 9 Jun 2023 00106861
74 6 Jun 2023 9 Jun 2023 00000727
75 5 Jun 2023 9 Jun 2023 00106846
76 7 Jun 2023 9 Jun 2023 00106805
77 6 Jun 2023 9 Jun 2023 00052424
78 7 Jun 2023 9 Jun 2023 00010600
79 7 Jun 2023 9 Jun 2023 00073165
80 2 Jun 2023 9 Jun 2023 00081009
81 7 Jun 2023 9 Jun 2023 00046519
82 7 Jun 2023 10 Jun 2023 00060395

Page 2
 sheet1 -1

83 7 Jun 2023 10 Jun 2023 00083446

84 7 Jun 2023 10 Jun 2023 00094845
85 9 Jun 2023 11 Jun 2023 00106972
86 8 Jun 2023 11 Jun 2023 00106840
87 8 Jun 2023 11 Jun 2023 00106970
88 7 Jun 2023 11 Jun 2023 00106297
89 10 Jun 2023 12 Jun 2023 00003920
90 10 Jun 2023 12 Jun 2023 00107008
91 10 Jun 2023 12 Jun 2023 00107005
92 10 Jun 2023 12 Jun 2023 00107011
93 12 Jun 2023 13 Jun 2023 00031410
94 10 Jun 2023 13 Jun 2023 00107002
95 7 Jun 2023 13 Jun 2023 00101637
96 11 Jun 2023 13 Jun 2023 00048236
97 7 Jun 2023 14 Jun 2023 00106887
98 12 Jun 2023 14 Jun 2023 00107066
99 10 Jun 2023 14 Jun 2023 00107009
100 13 Jun 2023 15 Jun 2023 00107084
101 12 Jun 2023 15 Jun 2023 00101786
102 13 Jun 2023 15 Jun 2023 00107100
103 13 Jun 2023 15 Jun 2023 00107083
104 13 Jun 2023 15 Jun 2023 00107097
105 12 Jun 2023 15 Jun 2023 00101691
106 9 Jun 2023 15 Jun 2023 00087707
107 9 Jun 2023 15 Jun 2023 00067093
108 12 Jun 2023 15 Jun 2023 00056003
109 13 Jun 2023 16 Jun 2023 00107102
110 13 Jun 2023 16 Jun 2023 00049277
111 14 Jun 2023 16 Jun 2023 00075186
112 14 Jun 2023 16 Jun 2023 00097389
113 15 Jun 2023 16 Jun 2023 00107137
114 13 Jun 2023 16 Jun 2023 00057815
115 14 Jun 2023 16 Jun 2023 00107129
116 14 Jun 2023 16 Jun 2023 00006561
117 14 Jun 2023 17 Jun 2023 00106847
118 14 Jun 2023 17 Jun 2023 00106875
119 15 Jun 2023 17 Jun 2023 00089720
120 15 Jun 2023 17 Jun 2023 00040092
121 15 Jun 2023 17 Jun 2023 00041120
122 16 Jun 2023 17 Jun 2023 00107157
123 16 Jun 2023 17 Jun 2023 00107159
124 14 Jun 2023 18 Jun 2023 00107094
125 16 Jun 2023 18 Jun 2023 00107173

Page 3
 sheet1 -1

126 15 Jun 2023 18 Jun 2023 00072192

127 15 Jun 2023 18 Jun 2023 00107154
128 16 Jun 2023 18 Jun 2023 00018176
129 14 Jun 2023 18 Jun 2023 00107130
130 16 Jun 2023 19 Jun 2023 00052763
131 17 Jun 2023 19 Jun 2023 00067099
132 15 Jun 2023 19 Jun 2023 00084478
133 17 Jun 2023 19 Jun 2023 00107202
134 18 Jun 2023 20 Jun 2023 00077731
135 18 Jun 2023 20 Jun 2023 00105258
136 17 Jun 2023 21 Jun 2023 00006010
137 17 Jun 2023 21 Jun 2023 00107203
138 19 Jun 2023 21 Jun 2023 00103816
139 19 Jun 2023 21 Jun 2023 00107208
140 19 Jun 2023 21 Jun 2023 00059654
141 19 Jun 2023 21 Jun 2023 00002125
142 20 Jun 2023 22 Jun 2023 00107274
143 21 Jun 2023 22 Jun 2023 00035263
144 19 Jun 2023 22 Jun 2023 00107272
145 20 Jun 2023 22 Jun 2023 00083910
146 20 Jun 2023 22 Jun 2023 00107291
147 19 Jun 2023 22 Jun 2023 00107221
148 20 Jun 2023 22 Jun 2023 00055027
149 20 Jun 2023 22 Jun 2023 00107313
150 20 Jun 2023 22 Jun 2023 00107277
151 20 Jun 2023 22 Jun 2023 00040781
152 20 Jun 2023 22 Jun 2023 00004354
153 20 Jun 2023 22 Jun 2023 00107212
154 20 Jun 2023 23 Jun 2023 00107228
155 22 Jun 2023 23 Jun 2023 00106836
156 21 Jun 2023 23 Jun 2023 00107341
157 21 Jun 2023 23 Jun 2023 00102762
158 20 Jun 2023 23 Jun 2023 00106189
159 21 Jun 2023 23 Jun 2023 00107329
160 21 Jun 2023 24 Jun 2023 00037334
161 22 Jun 2023 24 Jun 2023 00107324
162 22 Jun 2023 24 Jun 2023 00054566
163 21 Jun 2023 24 Jun 2023 00107351
164 21 Jun 2023 24 Jun 2023 00107353
165 23 Jun 2023 25 Jun 2023 00106678
166 23 Jun 2023 25 Jun 2023 00104254
167 21 Jun 2023 25 Jun 2023 00107331
168 25 Jun 2023 25 Jun 2023 00061846

Page 4
 sheet1 -1

169 24 Jun 2023 26 Jun 2023 00058412

170 22 Jun 2023 26 Jun 2023 00107366
171 21 Jun 2023 26 Jun 2023 00107333
172 24 Jun 2023 26 Jun 2023 00107451
173 18 Jun 2023 26 Jun 2023 00047287
174 26 Jun 2023 27 Jun 2023 00106882
175 26 Jun 2023 27 Jun 2023 00007663
176 23 Jun 2023 27 Jun 2023 00078192
177 26 Jun 2023 27 Jun 2023 00107465
178 23 Jun 2023 27 Jun 2023 00098226
179 21 Jun 2023 27 Jun 2023 00087967
180 25 Jun 2023 27 Jun 2023 00002747
181 25 Jun 2023 27 Jun 2023 00018687
182 26 Jun 2023 28 Jun 2023 00107479
183 26 Jun 2023 28 Jun 2023 00107225
184 26 Jun 2023 28 Jun 2023 00014073
185 26 Jun 2023 28 Jun 2023 00107464
186 26 Jun 2023 28 Jun 2023 00031018
187 25 Jun 2023 28 Jun 2023 00032132
188 27 Jun 2023 28 Jun 2023 00034593
189 26 Jun 2023 28 Jun 2023 00060680
190 25 Jun 2023 28 Jun 2023 00107459
191 26 Jun 2023 28 Jun 2023 00094957
192 26 Jun 2023 28 Jun 2023 00101743
193 26 Jun 2023 28 Jun 2023 00106311
194 26 Jun 2023 28 Jun 2023 00086956
195 26 Jun 2023 28 Jun 2023 00073744
196 27 Jun 2023 29 Jun 2023 00066238
197 26 Jun 2023 29 Jun 2023 00015777
198 27 Jun 2023 29 Jun 2023 00057253
199 27 Jun 2023 29 Jun 2023 00099560
200 27 Jun 2023 29 Jun 2023 00095249
201 26 Jun 2023 29 Jun 2023 00026279
202 26 Jun 2023 29 Jun 2023 00083219
203 27 Jun 2023 29 Jun 2023 00107180
204 27 Jun 2023 29 Jun 2023 00107546
205 26 Jun 2023 29 Jun 2023 00085792
206 28 Jun 2023 30 Jun 2023 00079556
207 25 Jun 2023 30 Jun 2023 00010430
208 27 Jun 2023 30 Jun 2023 00051989
209 28 Jun 2023 30 Jun 2023 00107566
210 28 Jun 2023 30 Jun 2023 00090388
211 27 Jun 2023 30 Jun 2023 00107563

Page 5
 sheet1 -1

Kode RS: 3404184

Page 6
 sheet1 -1

LAPORAN REKAP KLAIM - RS BHAYANGKARA SLEMAN

Pasien Rawat Inap dan Rawat Jalan, Periode Tanggal Pulang: 1 Jun 2023 s/d 30 Jun 2023
Filter: / Kelas Rawat = Semua / Severity = Semua / Cara Pulang = Semua / Jenis Tarif = TARIF RS KELAS D PEMERINTAH
Nama Pasien No. Klaim / SEP INACBG
SUWARDI HARDIWIYONO 0179R0060523V002601 K-4-17-II
INDAH YUANA PUTRI 0179R0060523V002586 O-6-10-I
TUGIRAH 0179R0060523V002536 D-4-13-I
MALIKA SAFAQUILA PUTRI 0179R0060523V002689 A-4-14-I
SRI LESTARI 0179R0060523V002682 N-4-12-I
ALDI BAGAS SEPTIANUDIN 0179R0060523V002543 M-1-80-I
BAMBANG SUWONDO 0179R0060523V002582 J-4-21-II
TRI SUSILOWATI 0179R0060523V002683 N-4-12-III
SUPARTI 0179R0060523V002505 I-4-19-III
GIMAN 0179R0060523V002597 B-4-13-II
DINDA NOORA ALFIOMITA 0179R0060523V002691 W-1-20-I
NURUL ANISAH 0179R0060523V002681 O-6-10-I
SUHARNI 0179R0060523V002812 B-4-14-III
NIKODEMUS YEINGO 0179R0060523V002408 K-4-18-I
RADHIKA DAREEN ALFARISQI 0179R0060623V000002 G-4-22-I
PARMAN WARNO SUPARJO 0179R0060523V002692 A-4-13-I
GATOT SUPRIYADI 0179R0060523V002778 M-1-50-I
BUDI ASTUTI 0179R0060523V002528 U-1-15-I
YENI NOVITA SARI 0179R0060523V002762 K-1-13-I
RUDIANTO 0179R0060523V002646 N-4-13-II
MUHAMMAD KEN AZKA RAFFASYA 0179R0060623V000023 J-4-21-I
SRI MULYANI 0179R0060623V000036 Z-4-12-III
FADILAH NURAINI 0179R0060523V002705 J-4-21-I
RESTU HAYYU KHOIRUNNISA 0179R0060523V002810 N-4-12-I
BASRIYAH 0179R0060523V002659 K-1-50-I
YENI IFO 0179R0060523V002805 K-4-18-I
ALESHA MAHARENI KEIKO 0179R0060623V000022 J-4-21-I
SYARIFAH ADAWIYAH 0179R0060523V002745 O-6-10-I
RENDI ADE WIJAYA 0179R0060523V002690 A-4-13-I
FADHILLAH YANUAR SARAH 0179R0060523V002684 A-4-14-I
TUMILAH 0179R0060623V000024 W-4-13-I
TUKIRAN PUJO HARTONO 0179R0060623V000020 G-4-14-II
SURANTI 0179R0060623V000001 O-6-10-I
PAINI WARDI WIYONO 0179R0060523V002385 I-4-15-III
NANDA NUR ROMADHONI 0179R0060623V000035 K-4-17-I
NEVI INDRIYANI 0179R0060623V000025 N-4-12-I
FAHREZA DIRJA LAKSANA 0179R0060623V000034 J-4-21-I
H.MUH. TAMRIN 0179R0060623V000075 Z-4-12-I
SUCI KURNIAWATI 0179R0060623V000021 W-4-13-I

Page 7
 sheet1 -1

SULASMI 0179R0060523V002721 A-4-13-III

RATNO ESTI PRANDONO 0179R0060523V002811 J-4-16-I
MANTO SUPARNO SUKIMAN 0179R0060623V000064 V-4-11-I
SARJITO 0179R0060623V000079 I-4-20-II
ALMAHYRA ANNISA RISKYANA 0179R0060623V000044 A-4-14-I
SUNARTI 0179R0060623V000045 O-6-13-II
BY NY SUNARTI 0179R0060623V000195 P-8-08-I
LIA RISTAWATI 0179R0060623V000042 B-4-14-I
SUWARNI 0179R0060623V000065 B-4-14-II
TUGIYEM 0179R0060623V000078 Z-4-12-III
MARDI WIYONO SUMARDI 0179R0060623V000080 K-1-14-I
SULISTYOWATI 0179R0060623V000043 N-4-12-I
WAHYU PUJI ASTUTI 0179R0060623V000253 O-6-10-I
MARJINAH 0179R0060623V000221 N-1-12-I
AGUS PURNOMO 0179R0060623V000316 B-4-14-II
PONIDI DIRJO WIYONO 0179R0060623V000077 J-4-15-I
MARITO 0179R0060623V000081 K-1-50-I
FAHMA AZALEA AFANIN 0179R0060623V000243 M-4-20-I
TANNIYO 0179R0060623V000083 A-4-14-II
IMAM MUSTOFA 0179R0060523V002658 I-4-12-II
MOLINGGAR PUJI LESTARI 0179R0060623V000279 O-6-10-I
ETMA AMBARWATI 0179R0060623V000311 W-1-20-I
LIANA 0179R0060623V000285 W-1-20-I
DEVI RIA ARTHASARI 0179R0060623V000465 Z-4-12-II
ADITYA DWI PRATAMA 0179R0060623V000231 N-4-12-I
KRISTIANA ARI GUNAWAN 0179R0060623V000381 K-4-18-II
HERLINA 0179R0060623V000387 L-1-40-I
SISWANTI 0179R0060623V000423 L-1-40-I
TRI RETNA ASIH 0179R0060623V000427 N-4-12-I
HERINOVI KUSUMAWATI 0179R0060623V000082 K-1-13-II
SURANTO HERU PRABOWO 0179R0060623V000244 B-4-14-I
DEVITA NUR WAHYUNI 0179R0060623V000519 D-4-13-I
MARYAM 0179R0060623V000315 I-4-24-III
AHMAD KHOIRUDDIN SIBARANI 0179R0060623V000524 L-1-40-I
HARTONO 0179R0060623V000371 I-4-15-I
HENDYNA DIAN ANGELLICA 0179R0060623V000394 A-4-13-I
HERMAWAN SUSILO UTOMO 0179R0060623V000547 U-1-15-I
KARTO WIHARJO NY 0179R0060623V000365 S-4-16-III
HAPSARI DWI PUSPORINI 0179R0060623V000428 I-4-17-II
SUMIYATI 0179R0060623V000443 J-4-16-I
ELISABETH CITRAWATI 0179R0060623V000046 D-4-13-III
DEVINA RIZQI ALMIRA 0179R0060623V000575 Z-4-11-I
DYAH GALIH PRASETYANINGTYAS 0179R0060623V000546 O-6-10-I

Page 8
 sheet1 -1

NABILA KHUSNIYYA ZAHREINA 0179R0060623V000572 A-4-13-I

MUHAMMAD WAHID RIDHO 0179R0060623V000573 J-1-30-I
ILYAS FARID NUGROHO 0179R0060623V000691 N-4-12-I
MAEYLIA DYAH PUTRIYANI 0179R0060623V000663 O-6-13-I
VIRA AISYA PUTRI 0179R0060623V000664 J-4-16-I
HARENDRA NAMAL DIAS GUNASINGHE 0179R0060623V000606 M-1-80-I
LUTFI NUR FADLIAH 0179R0060623V000811 O-6-10-I
MINUK PUJI RAHAYU 0179R0060623V000830 O-6-13-I
SURYANTO 0179R0060623V000829 L-1-30-I
ROCHMADI 0179R0060623V000835 J-4-16-I
BINA WIDAYATI 0179R0060623V000955 W-1-30-I
TUMIYEM 0179R0060623V000821 I-4-12-II
GIYATA 0179R0060623V000627 B-4-14-III
RESTHI HARPA OKTAVIA 0179R0060623V000833 J-4-16-I
AMRINA 0179R0060623V000429 G-4-14-I
ILHAM AJI PANGESTU 0179R0060623V000984 J-4-21-I
PONIYEM 0179R0060623V000831 J-4-21-II
NGATIJO 0179R0060623V001073 E-4-10-I
BASTIAN JAVAS DAMARIO 0179R0060623V000985 K-4-17-II
SEPTIAN TEGUH WIJIYANTO 0179R0060623V001080 I-4-20-I
BAMBANG HERMANTO 0179R0060623V001041 L-1-40-I
ARBANGATUN 0179R0060623V001070 N-4-12-I
SHAFFIRA NABILLA AZMIR 0179R0060623V000983 O-6-10-I
NY NGATIYEM 0179R0060623V000748 M-1-20-II
SRI LESTARI 0179R0060623V000797 E-4-10-II
TUGINEM 0179R0060623V000922 I-4-12-II
PARTI 0179R0060623V001082 M-4-17-I
DEDE MAULANA YUSUF 0179R0060623V001078 E-4-10-I
SLAMET WIDODO 0179R0060623V001198 I-4-15-I
INGGRIT ANGGRAENI KUSUMAH 0179R0060623V001210 O-6-10-I
SRI SUWANTI 0179R0060623V001223 W-4-13-I
MUH TAROM 0179R0060623V001075 E-4-10-I
RIKZIE LASARO VEKTORI 0179R0060623V001192 G-4-25-I
GIYADI 0179R0060623V001175 Z-4-12-III
ENDANG WAHYUNINGSIH 0179R0060623V001202 O-6-10-I
SUSANTI 0179R0060623V001196 O-6-10-I
NANANG SUSILO 0179R0060623V001222 N-4-12-I
ANING DWI PRATIWI 0179R0060623V001221 K-4-18-II
WAHUDI 0179R0060623V001323 G-4-23-I
PARJIYATI 0179R0060623V001368 I-4-17-I
MUHAMMAD ZAKI AL FATIH 0179R0060623V001394 K-1-14-I
ANDROMEDA QABALA ISLAMADINA 0179R0060623V001190 U-1-15-I
SUPARNO 0179R0060623V001396 G-4-14-I

Page 9
 sheet1 -1

ZIVANA ALEENA AYUNINDYA 0179R0060623V001322 A-4-13-I

SUWARNI SUTIYARTO 0179R0060623V001321 G-4-11-II
RAFA FAEYZA F.N 0179R0060623V001437 M-4-12-I
BY NY INGGRIT ANGGRAENI KUSUMAH 0179R0060623V001279 P-8-08-I
SHAHAENA NOURA ILKHAVA 0179R0060623V001359 J-4-21-I
ANNA CHATERINA MAX SABON 0179R0060623V001456 M-4-17-I
DIMITRIJ BANYU WILU RESPATI 0179R0060623V001290 J-4-21-I
S.AQILA SYAHIRA PUTRI ARIFIANTO 0179R0060623V001465 G-4-17-I
TINA YULIASTUTI 0179R0060623V001469 L-1-40-I
HARTINI 0179R0060623V001468 Z-4-12-I
NOVAL ALFIANDI PURNOMO 0179R0060623V001464 K-4-18-I
RAMADHANI FEBRIANA SURYA DEWI 0179R0060623V001466 B-4-14-I
SULISTYO BUDI HARNOWO 0179R0060623V001597 N-4-10-III
FIRA DENA MILENIA WIBAWA 0179R0060623V001561 L-4-12-I
AHMADI 0179R0060623V001555 B-4-13-I
PRATIDHINA HADHANA NABILAWATAN 0179R0060623V001591 D-1-20-I
ANGGRAENI PUSPITA DEWI SANTOSO 0179R0060623V001776 O-6-10-I
DANURI WARDIYONO 0179R0060623V001789 N-4-12-I
SUKIRMAN 0179R0060623V001614 N-4-12-I
RAGIL SAPUTRA 0179R0060623V001690 G-4-22-I
ZUSANA ADRIANA LAISATAMU 0179R0060623V001717 A-4-14-I
MENIK 0179R0060623V001581 M-1-20-I
NUR NITA ROHMAH 0179R0060623V001714 W-4-16-I
RAHMA PUTRI AULIA 0179R0060623V001719 J-4-16-I
SUGENG 0179R0060623V001696 K-1-14-I
SIGIT RAHARJO ST 0179R0060623V001716 N-4-10-III
BERWYN INAS MEGARA 0179R0060623V001702 L-1-40-I
GUSTOMI ALFIANDRI 0179R0060623V001695 L-1-40-I
TUKIDJO 0179R0060623V001693 K-1-14-I
JEMIYEM 0179R0060623V001892 O-6-13-I
ROHMATDI 0179R0060623V001809 M-1-80-I
GRACIA WIDIPUTRI SUDRAJAT 0179R0060623V001720 K-4-17-I
ANGGITA WULANDARI 0179R0060623V001713 O-6-10-I
SUMENEP 0179R0060623V001781 O-6-10-I
TRI WINDARSIH 0179R0060623V001830 O-6-10-I
SHIFA SUNDARI ANJANI 0179R0060623V001880 O-6-10-I
TUKIRAH 0179R0060623V001883 N-4-12-I
NURULIA FITRI RAMADHANI 0179R0060623V001907 N-4-12-I
SUYATI 0179R0060623V001844 K-4-18-II
ADITYA WINATA NUR HIDAYAT 0179R0060623V002023 N-4-10-I
ANISSA APRILIA 0179R0060623V001978 W-4-14-I
SULASTRI 0179R0060623V001786 Z-4-12-III
JUMONO 0179R0060623V002060 Z-4-12-III

Page 10
 sheet1 -1

ADITYA PRAMBAN SARI NINGTYAS 0179R0060623V002051 O-6-13-I

PAIYEM 0179R0060623V001872 G-4-14-I
SANIYEM 0179R0060623V001778 G-4-14-II
YOGA DWI NURHADI 0179R0060623V002059 G-4-22-I
MARSIYAH 0179R0060623V001467 G-4-13-II
WIDYA HESTI IRDIANY 0179R0060623V002206 D-4-13-I
PARJINI 0179R0060623V002066 I-4-17-I
HASBI AL GHIFARI IBRAHIM 0179R0060623V002026 J-4-16-I
STEPHANUS SUPARDI 0179R0060623V002068 I-4-17-I
DALIMO MARDI WIYANA 0179R0060623V002015 E-4-10-I
TUKIYEM 0179R0060623V001843 J-4-21-II
SITI NURCHAYATI 0179R0060623V002061 L-1-40-I
MARIA KRISTIANA 0179R0060623V002062 L-1-50-I
AMELINDA ZAHRA AMINAR SYAHPUTRI 0179R0060623V002193 L-4-12-I
MUHAMAD JENAL MUSTOPA 0179R0060623V002168 U-1-15-I
TSAQIB ZAHRONI 'AFFAN 0179R0060623V002176 M-1-40-I
UKASYA SHAKA KAFEEL 0179R0060623V002067 G-4-22-I
YOKA MARU BASMARA BANGSA 0179R0060623V002260 M-1-40-I
FAREZA DAWAMZUHDI PAMUNGKAS 0179R0060623V002065 K-4-17-I
ERNI NURHASANAH 0179R0060623V002334 O-6-13-I
RIAN ANGGARA 0179R0060623V002220 S-4-11-I
NUR SALIM 0179R0060623V002064 K-1-50-I
ABYANTARA DWI SUSILO 0179R0060623V002172 V-4-11-I
DYAH AYU NATALIA 0179R0060623V002196 M-4-21-II
DHAFIN RASYA SABILA 0179R0060623V002180 D-1-20-I
CEMPAKA ARUM HUTOMO 0179R0060623V002080 J-4-21-I
IKE YUNIARTI 0179R0060623V002166 D-1-20-I
RISKI MELIANA PUTRI 0179R0060623V002265 N-4-12-I
LINDA ROMADHONI TRI HASANAH 0179R0060623V002200 N-4-12-I
FERRY PONCO WINDOKO 0179R0060623V002278 M-4-17-I
SUTRIYATI 0179R0060623V002300 I-4-17-II
DHANY ADITYA SAPUTRA 0179R0060623V002223 N-4-10-III
ROMADONA FITRIYATUN 0179R0060623V002199 O-6-10-I
KAWIT RATMO SUWITO 0179R0060623V002221 D-4-13-III
SUJADI 0179R0060623V002222 I-4-15-I
SAKIRAH 0179R0060623V002325 I-4-12-II
ENY RENITASARI 0179R0060623V002216 O-6-10-I
SRI WARSITO 0179R0060623V002348 G-4-14-I
PARTANA 0179R0060623V002063 J-4-21-II
SHANTI CAHYA BAGYASTUTI 0179R0060623V002320 G-4-23-I
CUCI HASTUTI 0179R0060623V002337 W-4-12-I
DWI MYLONO ARIVANTO 0179R0060623V002352 V-4-11-II
HESTI INDARTI 0179R0060623V002336 J-4-16-II

Page 11
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Page 12
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un 2023
KELAS D PEMERINTAH
Top Up Total Tarif Tarif RS Jenis
1,801,300 2,000,704 RI
4,521,100 4,871,838 RI
2,037,000 3,566,604 RI
2,929,600 1,988,500 RI
2,144,100 1,685,500 RI
7,008,900 14,371,000 RI
5,701,500 3,481,306 RI
6,402,500 2,051,300 RI
4,975,200 3,208,104 RI
4,023,400 4,317,508 RI
6,565,600 6,868,500 RI
4,521,100 4,850,938 RI
4,475,700 4,150,104 RI
1,141,300 4,858,104 RI
2,525,400 1,267,300 RI
1,628,700 3,334,104 RI
3,879,400 6,370,700 RI
2,988,900 8,459,900 RI
3,582,800 6,077,600 RI
3,919,600 2,877,004 RI
3,100,100 1,538,800 RI
2,501,000 3,580,804 RI
2,661,000 2,558,700 RI
2,497,900 2,559,600 RI
4,872,500 4,659,300 RI
1,517,900 3,285,800 RI
3,100,100 1,444,900 RI
4,521,100 5,140,538 RI
1,628,700 2,627,400 RI
2,929,600 5,658,606 RI
1,528,000 1,485,100 RI
4,570,400 2,416,204 RI
4,521,100 4,967,738 RI
6,957,900 11,551,204 RI
1,227,400 1,331,900 RI
2,497,900 3,159,304 RI
2,661,000 1,192,700 RI
1,695,600 2,740,104 RI
1,528,000 1,845,100 RI

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2,995,600 5,313,404 RI
3,882,500 3,774,304 RI
2,933,800 3,429,404 RI
4,270,300 2,582,904 RI
2,202,700 1,649,100 RI
2,995,200 3,200,689 RI
3,767,000 1,301,600 RI
3,809,200 5,011,804 RI
3,467,600 3,538,904 RI
2,501,000 4,029,806 RI
4,159,000 5,000,100 RI
2,144,100 3,121,804 RI
4,521,100 4,654,938 RI
3,396,500 4,135,400 RI
4,611,800 3,931,404 RI
4,659,700 4,800,502 RI
4,872,500 4,599,700 RI
1,999,600 2,444,300 RI
3,114,900 3,223,904 RI
3,194,000 8,127,704 RI
4,521,100 4,732,838 RI
5,635,700 5,862,500 RI
6,565,600 6,501,600 RI
2,030,100 2,011,304 RI
2,144,100 2,107,900 RI
1,889,200 2,654,000 RI
3,700,600 4,007,300 RI
3,700,600 4,260,100 RI
2,144,100 1,529,000 RI
3,129,300 6,080,704 RI
3,809,200 4,660,204 RI
2,373,100 2,226,304 RI
5,982,500 5,550,808 RI
4,921,700 7,034,400 RI
4,965,300 6,049,700 RI
1,628,700 2,246,404 RI
3,482,100 7,135,500 RI
7,349,800 3,035,204 RI
2,385,200 2,643,504 RI
3,882,500 3,174,704 RI
4,904,200 6,866,306 RI
1,987,800 6,132,308 RI
5,267,100 5,446,935 RI

Page 14
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2,166,100 4,373,106 RI
6,474,200 6,904,704 RI
2,144,100 1,527,100 RI
2,009,700 3,040,474 RI
3,332,600 1,531,500 RI
8,001,500 10,428,604 RI
4,521,100 4,757,938 RI
2,009,700 2,825,354 RI
6,058,600 5,191,700 RI
3,332,600 2,616,404 RI
3,706,300 4,393,000 RI
2,741,600 3,344,304 RI
4,475,700 4,145,506 RI
3,332,600 1,568,000 RI
4,546,800 11,319,004 RI
3,100,100 1,641,300 RI
4,286,800 4,120,104 RI
3,331,000 1,774,004 RI
2,098,500 2,181,900 RI
4,067,100 2,255,404 RI
4,921,700 6,577,800 RI
2,497,900 2,122,551 RI
4,521,100 5,102,038 RI
11,580,700 12,351,300 RI
4,654,000 3,927,404 RI
2,741,600 3,050,404 RI
2,515,100 2,399,100 RI
4,430,200 5,356,204 RI
4,262,100 4,871,004 RI
5,267,100 5,228,835 RI
1,311,600 1,174,100 RI
3,331,000 2,788,606 RI
2,287,700 3,853,700 RI
2,913,600 3,919,406 RI
4,521,100 4,739,538 RI
4,521,100 4,815,338 RI
2,144,100 2,535,004 RI
1,621,600 1,769,402 RI
1,807,300 1,346,500 RI
1,934,500 1,670,704 RI
4,159,000 5,314,000 RI
3,482,100 7,041,200 RI
3,418,600 2,985,502 RI

Page 15
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1,897,400 1,763,100 RI
5,342,600 4,156,704 RI
2,255,000 3,702,400 RI
4,388,600 3,361,100 RI
3,100,100 2,031,400 RI
2,515,100 2,151,304 RI
3,100,100 3,178,300 RI
3,067,000 1,332,600 RI
4,311,200 6,934,300 RI
1,274,900 3,732,304 RI
1,329,600 3,842,800 RI
2,864,000 3,830,104 RI
6,149,000 2,797,904 RI
1,850,300 5,846,500 RI
3,813,300 3,075,402 RI
4,103,100 5,738,800 RI
5,267,100 5,864,935 RI
2,144,100 1,588,000 RI
2,144,100 2,115,104 RI
2,942,100 1,924,500 RI
2,929,600 3,624,604 RI
8,868,900 7,288,802 RI
2,007,700 1,153,200 RI
3,332,600 1,644,300 RI
4,159,000 4,801,500 RI
5,386,100 3,100,704 RI
4,311,200 5,726,100 RI
4,311,200 6,745,600 RI
4,159,000 5,037,700 RI
2,009,700 2,606,474 RI
6,016,200 7,078,100 RI
1,632,400 2,514,604 RI
6,013,100 6,968,132 RI
4,521,100 4,788,338 RI
4,521,100 4,838,938 RI
5,267,100 5,534,835 RI
2,144,100 2,045,900 RI
2,144,100 2,334,800 RI
1,621,600 2,287,804 RI
3,014,800 3,660,309 RI
2,055,500 1,317,900 RI
2,501,000 5,722,404 RI
2,501,000 1,315,404 RI

Page 16
 sheet1 -1

2,672,900 3,354,004 RI
3,418,600 3,202,202 RI
4,570,400 4,966,302 RI
2,942,100 3,151,800 RI
4,117,000 11,316,404 RI
2,373,100 3,201,709 RI
1,934,500 1,437,704 RI
4,432,400 3,950,700 RI
2,572,800 2,026,504 RI
3,331,000 2,694,706 RI
4,994,100 4,757,404 RI
4,311,200 6,573,700 RI
5,192,400 6,906,300 RI
1,620,800 5,879,400 RI
3,975,300 6,688,900 RI
3,718,200 6,078,404 RI
2,942,100 1,707,200 RI
3,718,200 5,314,104 RI
1,429,900 2,780,604 RI
2,341,300 2,780,489 RI
1,561,200 2,018,704 RI
5,676,500 6,632,600 RI
3,349,400 6,308,600 RI
4,092,100 2,092,700 RI
4,103,100 5,328,400 RI
2,661,000 1,504,300 RI
4,103,100 6,711,500 RI
2,851,600 1,975,500 RI
2,497,900 3,548,000 RI
3,345,100 2,448,700 RI
2,385,200 3,508,504 RI
5,386,100 5,122,204 RI
4,521,100 4,855,738 RI
3,687,300 3,464,306 RI
4,262,100 4,780,000 RI
3,194,000 1,966,304 RI
5,267,100 5,510,735 RI
3,418,600 4,019,404 RI
5,701,500 5,261,704 RI
2,105,500 5,086,500 RI
2,671,300 1,296,700 RI
4,494,000 2,604,904 RI
4,683,200 2,294,904 RI

Page 17
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Total 753,682,600 847,314,136

Page 18