Daftar Tarif PIK

Kelompok Tarif 2 - IPM

No JENIS IPM TARIF

2. Injeksi IPM Berpandu USG
2.1. Regio 1 - Head & Spine
2101 IPM USG -Blepharospasm 7,600,000
2102 IPM USG - Trigeminal Block 9,500,000
2103 IPM USG - Trigeminal V1/V2/V3 7,600,000
2104 IPM USG - Trigeminal Block Additional 3,800,000
2105 IPM USG - Hemifasial spasm 7,600,000
2106 IPM USG - Hemifasial spasm Bilateral 9,500,000
2107 IPM USG - Hemineck spasm 7,600,000
2108 IPM USG - Hemineck spasm Bilateral 9,500,000
2109 IPM USG - Dystonia 7,600,000
2110 IPM USG - Dystonia Bilateral 9,500,000
2111 IPM USG - Cluster Headache 7,600,000
2112 IPM USG - Migrain Headache 7,600,000
2113 IPM USG - Tension Headache 7,600,000
2114 IPM USG - TMJ (Temporo Mandibular Joint) 7,600,000
2115 IPM USG - TMJ Pain Bilateral 9,500,000
2116 IPM USG - Stellate Block 9,500,000
2117 IPM USG - Lumbar Sympathetic Block 9,500,000
2118 IPM USG - Ganglion Impar Block 9,500,000
2119 IPM USG - Coccyx Block 9,500,000
2120 IPM USG - Coeliac Plexus Block 9,500,000
2121 IPM USG - Superior Hypogastric Block 9,500,000
2122 IPM USG - Brachialis Plexus Block 9,500,000
2123 IPM USG - Cervical Nerve Root Block 7,600,000
2124 IPM USG - Cervical Nerve Root Block Additional 3,800,000
2125 IPM USG - Greater Occipital Nerve 7,600,000
2126 IPM USG - Greater Occipital Nerve Bilateral 9,500,000
2127 IPM USG - Radiculopathy Cervical 7,600,000
2128 IPM USG - Facet Joint Cervical Arthropathy 7,600,000
2129 IPM USG - Facet Joint Cervical Arthropathy Additional 3,800,000
2130 IPM USG - Medial Branch Block 7,600,000
2131 IPM USG - Medial Branch Block Additional 3,800,000
2132 IPM USG - Cervical Headache 7,600,000
2133 IPM USG - Myofascial Trigger Point Block / MTPS 7,600,000
2134 IPM USG - MTPS Block Additional 1,900,000
2135 IPM USG - Radiculopathy Thoracal 7,600,000
2136 IPM USG - Facet Joint Thoracalis Arthropathy 7,600,000
2137 IPM USG - Facet Joint Thoracalis Arthropathy Additional 3,800,000
2138 IPM USG - Intercostal Nerve Block 9,500,000
2139 IPM USG - Intercostal Nerve Block Additional 3,800,000
2140 IPM USG - Radiculopathy Lumbal 7,600,000
2141 IPM USG - Facet Joint Lumbal Arthropathy 7,600,000
2142 IPM USG - Facet Joint Lumbal Arthropathy Additional 3,800,000
2143 IPM USG - CRPS 2 (causalgia), CRPS 1 7,600,000
2144 IPM USG - Caudal epidural 7,600,000
2145 IPM USG - Coccydinia 7,600,000
2146 IPM USG - Iliohypogastric Nerve 5,700,000
2147 IPM USG - Entrapment N.Ilioinguinalis 5,700,000
2148 IPM USG - Entrapment N.Iliohipogastric 5,700,000
2149 IPM USG - Entrapment N.Pudendalis 5,700,000
2150 IPM USG - Entrapment N.Cluneal 5,700,000
 2151 IPM USG - Piriformis 3,800,000
2152 IPM USG - Sacroilliac joint 3,800,000
2153 IPM USG - Tuber ischii 3,800,000
2154 IPM USG - Meralgia Pharastetica 5,700,000
2155 IPM USG - Phantom Pain 7,600,000
2156 IPM USG - Nerve Block On Head & Spine 7,600,000
2157 IPM USG - Nerve Block On Head & Spine Additional 2,700,000

2.2. Regio 2 - Upper Extremity

2201 IPM USG - OA Shoulder / Intra Articular Injection 5,700,000
2202 IPM USG - Biceps 3,800,000
2203 IPM USG - Acromioclavicular joint 3,800,000
2204 IPM USG - Glenuhumeral joint 5,700,000
2205 IPM USG - Subscapular 3,800,000
2206 IPM USG - Subscapular Tear 3,800,000
2207 IPM USG - Supraspinatus 3,800,000
2208 IPM USG - Supraspinatus Tear 3,800,000
2209 IPM USG - Subacromial Subdeltoid Bursa (SASD) 3,800,000
2210 IPM USG - Frozen Shoulder 5,700,000
2211 IPM USG - Entrapment N.Axillary / Hydrodisection 5,700,000
2212 IPM USG - Elbow Joint 3,800,000
2213 IPM USG - Golfer Elbow / Common Flexor Tendon 3,800,000
2214 IPM USG - Tennis Elbow / Common Extensor Tendon 3,800,000
2215 IPM USG - Triceps Tendon / Olecranon Bursa 3,800,000
2216 IPM USG - Spastitas Upper Extremity 7,600,000
2217 IPM USG - PIN Block (Posterior Interoseus Nerve) 5,700,000
2218 IPM USG - Cubital Tunnel Block /Hydrodisection 5,700,000
2219 IPM USG - Post Herpetic Neuropathy (PHN) 7,600,000
2220 IPM USG - Wrist Joint 1 3,800,000
2221 IPM USG - Wrist Joint 2 5,700,000
2222 IPM USG - Wrist Joint 3 7,600,000
2223 IPM USG - Wrist Extensor Tendon 3,800,000
2224 IPM USG - TFCC 3,800,000
2225 IPM USG - Compartement Wrist 3,800,000
2226 IPM USG - Dequervain Block 3,800,000
2227 IPM USG - Carpal Tunnel Block /Hydrodisection 5,700,000
2228 IPM USG - Canal Guyon Block /Hydrodisection 5,700,000
2229 IPM USG - Trigger Finger 3,800,000
2230 IPM USG - Trigger Finger Additional 1,900,000
2231 IPM USG - Interphalangeal joint 3,800,000
2232 IPM USG - Interphalangeal joint Additional 1,900,000
2233 IPM USG - Finger Joint 3,800,000
2234 IPM USG - Finger Joint Additional 1,900,000
2235 IPM USG - Metacarpophalangeal Joint 3,800,000
2236 IPM USG - Metacarpophalangeal Joint Additional 1,900,000
2237 IPM USG - Ligamentt 3,800,000
2238 IPM USG - Nerve Block On Upper Extremity 5,700,000
2239 IPM USG - Nerve Block On Upper Extremity Additional 1,900,000

2.3. Regio 3 - Lower Extremity

2301 IPM USG - Entrapment N.Femoralis 5,700,000
2302 IPM USG - Entrapment N.Genitofemoralis 5,700,000
2303 IPM USG - Hamstring 3,800,000
2304 IPM USG - Bursitis Tuberischii 3,800,000
2305 IPM USG - Hip Joint 5,700,000
2306 IPM USG - Greater Trochanter Bursa 5,700,000
 2307 IPM USG - Hip Adductor Tendon 5,700,000
2308 IPM USG - OA Hip / Intra Articular Hip Joint 5,700,000
2309 IPM USG - Tear ACL 5,700,000
2310 IPM USG - Tear PCL 5,700,000
2311 IPM USG - Knee Joint 3,800,000
2312 IPM USG - Infrapatellar Bursa 3,800,000
2313 IPM USG - Suprapatelar Bursa / Bursitis Suprapatellar 3,800,000
2314 IPM USG - Medial Collateral Ligamentt 3,800,000
2315 IPM USG - Tear Ligamentt 5,700,000
2316 IPM USG - Pes Anserine Bursa / Bursitis Pes Anserinus 3,800,000
2317 IPM USG - Baker Cyst 3,800,000
2318 IPM USG - Illio Tibial Band (ITB) Bursitis 5,700,000
2319 IPM USG - Achilles Tendon 3,800,000
2320 IPM USG - Plantar Fascia 3,800,000
2321 IPM USG - Tibial Nerve Block 5,700,000
2322 IPM USG - Ankle Joint 3,800,000
2323 IPM USG - Subtalar Joint 3,800,000
2324 IPM USG - Tarsal Tunnel Block 5,700,000
2325 IPM USG - Baxter Nerve Entrapment 5,700,000
2326 IPM USG - ATFL Injury 5,700,000
2327 IPM USG - Ligamentt Injury 5,700,000
2328 IPM USG - Metatarsalgia 3,800,000
2329 IPM USG - Metatarsophalangeal Joint 3,800,000
2330 IPM USG - Morton Neuroma 5,700,000
2331 IPM USG - Toe Joint 3,800,000
2332 IPM USG - Toe Joint Additional 1,900,000
2333 IPM USG - Halux Valgus / Bunion 3,800,000
2334 IPM USG - Neuropaty Perifer 5,700,000
2335 IPM USG - Spastitas Lower Extremity 7,600,000
2336 IPM USG - Nerve Block On Lower Extremity 5,700,000
2337 IPM USG - Nerve Block On Lower Extremity Additional 1,900,000
2.4. Tambahan Modalitas / Substans
2401 IPM USG Prolotherapi -
2402 IPM USG Fluid Aspiration 1,900,000
2403 IPM USG Fenestration 1,900,000
2404 IPM USG Barbotation 1,900,000
2405 IPM USG Tenotomy 1,900,000
2406 IPM USG PRP 12,400,000
2407 IPM USG Ozone 1,900,000
2408 IPM USG Radio Frequency Ablation/Pulse 17,400,000
2409 IPM USG Cryo Ablation 20,000,000
2410 IPM USG Viscosupplementation Joint 3,900,000
2411 IPM USG Viscosupplementation Non Joint (2 syring) 4,700,000
2412 IPM USG Botullinum Toxin Kecil 3,400,000
2413 IPM USG Botullinum Toxin Besar 5,400,000