NO

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43

NAMA TINDAKAN
EEG
NCV
EMG
NCV + EMG
EVOKED POTENTIAL
FUNGSI LUHUR DIAGNOSIS
FUNDUSKOPI
TCD
DUPLEX PERIFER
CAROTID DOPLER
USG NEUROMUSCULAR
TRIGGER POINT MANUAL
INTRAARTICULAR 1 MANUAL
INTRAARTICULAR 1 USG
INTRAARTICULAR 2 MANUAL
INTRAARICULAR 2 USG
CARPAL TUNNEL SYNDROME MANUAL
CARPAL TUNNEL SYNDROME USG
DE QUERVAIN SYNDROME MANUAL
DE QUERVAIN SYNDROME USG
GUYON SYNDROME MANUAL
GUYON SYNDROME USG
TENNIS ELBOW MANUAL
TENNIS ELBOW USG
GOLFER ELBOW MANUAL
GOLFER ELBOW USG
TENDINITIS BICIPPITALIS MANUAL
TENDINITIS BICIPPITALIS USG
IMPINGEMENT USG
SUPRA SCAPULAR USG
SUPRA SCAPULAR CARM
GLENO-HUMERAL USG
GLENO-HUMERAL CARM
ACROMIO-CLAVICULAR JOINT USG
TERES MAYOR USG
TRIGGER FINGER MANUAL
TRIGGER FINGER USG
FASCITIS PLANTARIS MANUAL
FASCITIS PLANTARIS USG
TARSAL TUNNEL SYNDROME MANUAL
TARSAL TUNNEL SYNDROME USG
TENDINITIS PATELLA MANUAL
TENDINITIS PATELLA USG

TARIF JASA MEDIS DOKTER SPESIALIS SA

ICD IX-CM
F1
84.19
20
20
93.08
20
93.08
20
95.23
20
20
16.21
20
20
20
88.71
20
88.79
20
20
20
20
20
20
4.43
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
82.01
20
20
20
20
4.44
20
20
20
20

44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71

TENDINITIS PATELLA CARM

BAKER'S CYST MANUAL
BAKER'S CYST USG
FEMORAL ENTRAPMENT USG
PIRIFORMIS SYNDROME USG
PIRIFORMIS SYNDROME CARM
SACROILLIAC JOINT DYSFUNCTION USG
SACROILLIAC JOINT DYSFUNCTION CARM
LUMBAR FACET JOINT INJECTION USG
LUMBAR FACET JOINT INJECTION CARM
LUMBAR MEDIAN BRANCH INJECTION USG
LUMBAR MEDIAN BRANCH INJECTION CARM
LUMBAR TRANSFORAMINAL INJECTION USG
LUMBAR TRANSFORAMINAL INJECTION CARM
LUMBAR INTERLAMINAR INJECTION USG
LUMBAR INTERLAMINAR INJECTION CARM
LIMBAR INTRADISCAL INJECTION USG
LUMBAR INTRADISCAL CARM
SACRAL TRANSFORAMINAL INJECTION USG
SACRAL TRANSFORAMINAL INJECTION CARM
SACRAL EPIDURAL INJECTION MANUAL
SACRAL EPIDURAL INJECTION USG
SACRAL EPIDURAL INJECTION CARM
SERVIKAL FACET JOINT INJECTION CARM
SERVIKAL MEDIAN BRANCH INJECTION USG
SERVIKAL MEDIAN BRANCH INJECTION CARM
SERVIKAL INTERLAMINAR INJECTION USG
SERVIKAL INTERLAMINAR INJECTION CARM

83.39

20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20

S DOKTER SPESIALIS SARAF (NEUROLOGI)

F2.1
F2.2
F3
90
5
5
90
5
5
90
5
5
90
5
5
90
5
5
90
5
5
90
5
5
90
5
5
90
5
5
90
5
5
90
5
5
90
15
15
90
15
15
90
15
15
90
15
15
90
15
15
90
15
15
90
15
15
90
15
15
90
15
15
90
15
15
90
15
15
90
15
15
90
15
15
90
15
15
90
15
15
90
15
15
90
15
15
90
15
15
90
15
15
90
15
15
90
15
15
90
15
15
90
15
15
90
15
15
90
15
15
90
15
15
90
15
15
90
15
15
90
15
15
90
15
15
90
15
15
90
15
15

F4
10
10
10
10
10
10
5
10
10
10
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
10
5
10
5
5
5
5
5
5
5
5
5
5

TOTAL SKOR
130
130
130
130
130
130
125
130
130
130
125
145
145
145
145
145
145
145
145
145
145
145
145
145
145
145
145
145
145
145
150
145
150
145
145
145
145
145
145
145
145
145
145

RVU
5000
5000
5000
5000
10000
5000
5000
5000
5000
5000
5000
2000
2000
5000
2000
5000
2000
5000
2000
5000
2000
5000
2000
5000
2000
5000
2000
5000
5000
5000
10000
5000
10000
5000
5000
10000
15000
10000
15000
10000
15000
10000
15000

90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90

15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15

15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15

10
5
5
5
5
10
5
10
5
10
10
10
5
10
5
10
5
10
5
10
5
5
10
15
10
15
10
15

150
145
145
145
145
150
145
150
145
150
150
150
145
150
145
150
145
150
145
150
145
145
150
155
150
155
150
155

20000
10000
15000
15000
15000
20000
15000
20000
15000
20000
15000
20000
15000
20000
15000
20000
15000
20000
15000
20000
10000
15000
20000
20000
15000
20000
15000
20000

JASA
650,000
650,000
650,000
700,000
1,300,000
650,000
625,000
650,000
650,000
650,000
625,000
290,000
290,000
725,000
290,000
725,000
290,000
725,000
290,000
725,000
290,000
725,000
290,000
725,000
290,000
725,000
290,000
725,000
725,000
725,000
1,500,000
725,000
1,500,000
725,000
725,000
1,450,000
2,175,000
1,450,000
2,175,000
1,450,000
2,175,000
1,450,000
2,175,000

3,000,000
1,450,000
2,175,000
2,175,000
2,175,000
3,000,000
2,175,000
3,000,000
2,175,000
3,000,000
2,250,000
3,000,000
2,175,000
3,000,000
2,175,000
3,000,000
2,175,000
3,000,000
2,175,000
3,000,000
1,450,000
2,175,000
3,000,000
3,100,000
2,250,000
3,100,000
2,250,000
3,100,000