| 1 |
ADMINISTRASI |
|
| 2 |
Pasien Baru |
25.000 |
| 3 |
Pasien Lama |
10.000 |
| 4 |
|
|
| 5 |
OBAT, PERAWATAN UMUM, PENAMBAHAN PERAWATAN & LAINNYA |
|
| 6 |
Konsultasi (Tanpa Pemeriksaan) |
0 / Gratis |
| 21 |
Biaya Obat |
50.000 |
| 22 |
Obat Kumur Minosep 0,1% 60 ml (Hijau) |
40.000 |
| 23 |
Konsultasi, Pemeriksaan Gigi + Intra Oral Camera |
115.000 |
| 24 |
Intra Oral Camera |
50.000 |
| 25 |
Scaling Gigi |
350.000 |
| 26 |
Flouride |
60.000 |
| 27 |
Kuretase Gigi |
275.000 |
| 30 |
Root Planing |
250.000 |
| 31 |
Oklusal Adjustment |
165.000 |
| 32 |
Aplikasi Ties (Metronidazol) |
165.000 |
| 33 |
Apliasi Tooth Mousse |
115.000 |
| 34 |
Irigasi NaOCl, H2O2 |
115.000 |
| 35 |
Fissure Sealant pergigi |
280.000 |
| 39 |
Topikal Fluoride |
250.000 |
| 40 |
Pasak Fiber |
290.000 |
| 43 |
Mouth Guard |
775.000 |
| 44 |
Plate TMJ |
775.000 |
| 45 |
Gummy Smile |
525.000 |
| 46 |
Mahkota Sementara |
265.000 |
| 47 |
Penambahan Gigi Palsu Lepasan Standar (1 GIGI) |
260.000 |
| 51 |
Penambahan Gigi Palsu Lepasan Ortholux (1 GIGI) |
360.000 |
| 52 |
Cetak Alginate (1 Rahang) |
110.000 |
| 53 |
Cetak Alginate (2 Rahang) |
200.000 |
| 54 |
Orthokit |
50.000 |
| 58 |
|
|
| 59 |
PERAWATAN SALURAN AKAR GIGI & PENAMBALAN GIGI |
|
| 65 |
Penambalan Gigi Sementara |
225.000 |
| 67 |
Sterilisasi Saluran Akar Tunggal |
250.000 |
| 68 |
Sterilisasi Saluran Akar Ganda |
300.000 |
| 77 |
Anestesi |
150.000 |
| 78 |
Open Bur |
225.000 |
| 87 |
Pengisian Saluran Akar |
285.000 |
| 88 |
Penambalan Gigi GIC Kecil |
280.000 |
| 89 |
Penambalan Gigi GIC Besar |
330.000 |
| 90 |
Penambalan Gigi Komposite Kecil |
305.000 |
| 91 |
Penambalan Gigi Komposite Sedang |
325.000 |
| 92 |
Penambalan Gigi Komposite Besar |
360.000 |
| 93 |
Penambalan Gigi  Metode Sandwich |
475.000 |
| 94 |
Penambalan Gigi Depan |
770.000 |
| 95 |
Pengisian Saluran Akar & Penambalan Gigi |
740.000 |
| 96 |
|
|
| 97 |
PENCABUTAN GIGI |
|
| 98 |
Pencabutan Gigi Susu Tanpa Suntik |
200.000 |
| 99 |
Pencabutan Gigi Susu dengan Suntik |
225.000 |
| 100 |
Pencabutan Gigi Dewasa 1 Akar (Termasuk Obat) |
300.000 |
| 101 |
Pencabutan Gigi Dewasa lebih 1 Akar (Termasuk Obat) |
350.000 |
| 102 |
Cabut Gigi dewasa dengan faktor penyulit |
530.000 |
| 103 |
Batal Pencabutan Gigi sesudah Anestesi |
175.000 |
| 104 |
Batal Pencabutan Gigi tanpa Anestesi |
150.000 |
| 105 |
|
|
| 106 |
PERAWATAN GIGI ANAK |
|
| 107 |
Fissure Sealant |
|
| 108 |
Fissure Sealant Gigi Susu Anak |
280.000 |
| 109 |
Fissure Sealant Gigi Tetap Remaja |
325.000 |
| 110 |
Remineralising Agents |
300.000 |
| 125 |
Mouth Guard Anak |
775.000 |
| 143 |
Space Maintainer |
775.000 |
| 144 |
Stainless Steel Crown |
25.000 |
| 145 |
Celluloid Crown |
25.000 |
| 146 |
|
|
| 147 |
VENEER GIGI |
|
| 148 |
Veneer Gigi Composite Direct |
770.000 |
| 149 |
Veneer Gigi All Porcelain Emax |
3.225.000 |
| 150 |
Veneer Gigi All Porcelain Zirconia |
3.525.000 |
| 151 |
Opaquer |
250.000 |
| 152 |
Lepas Veneer Composite Direct |
165.000 |
| 153 |
Lepas Veneer Porcelain |
275.000 |
| 154 |
|
|
| 156 |
BEDAH MULUT |
|
| 157 |
(DENGAN PERJANJIAN DOKTER GIGI SP. BM) |
|
| 158 |
Pencabutan Gigi Dewasa |
1.000.000 - 1.500.000 |
| 159 |
Odontectomy / Operasi Gigi Bungsu |
2.000.000 - 3.500.000 |
| 160 |
(Sudah Termasuk Jahit dan Spongostan) |
- |
| 161 |
Frenektomi Gigi Bungsu |
1.500.000 - 2.000.000 |
| 162 |
Gingivektomi |
200.000 |
| 164 |
Operasi Reseksi Apeks Satu Akar |
1.550.000 |
| 165 |
Implan Gigi |
20.000.000 |
| 166 |
Frenektomi |
1.550.000 |
| 167 |
Operculectomy |
800.000 |
| 168 |
Mucocel |
800.000 |
| 169 |
|
|
| 170 |
FULL DENTURE atau GIGI PALSU PENUH 4 - 10 HARI |
|
| 171 |
Full Denture Bahan Akrilik 1 Rahang |
3.550.000 |
| 172 |
Full Denture Bahan Akrilik 2 Rahang |
6.550.000 |
| 173 |
Full Denture Bahan Thermosens 1 Rahang |
4.550.000 |
| 174 |
Full Denture Bahan Thermosens 2 Rahang |
8.550.000 |
| 175 |
|
|
| 176 |
EXPRESS GIGI PALSU atau GIGI TIRUAN LEPASAN 1 - 3 HARI |
|
| 177 |
Gigi Palsu Bahan Akrilik & 1 Gigi |
1.400.000 |
| 178 |
Gigi Palsu Bahan Valplast / Flexy & 1 Gigi |
1.900.000 |
| 179 |
Gigi Palsu Bahan Thermosens & 1 Gigi |
2.360.000 |
| 180 |
|
|
| 181 |
GIGI PALSU atau GIGI TIRUAN LEPASAN 3 - 6 HARI |
|
| 182 |
Gigi Palsu Bahan Akrilik & 1 Gigi |
1.160.000 |
| 183 |
Gigi Palsu Bahan Valplast / Flexy & 1 Gigi |
1.400.000 |
| 184 |
Gigi Palsu Bahan Thermosens & 1 Gigi |
1.860.000 |
| 185 |
|
|
| 186 |
GIGI PALSU PERMANEN, CROWN, BRIDGE atau VENEER PORCELAIN 4 - 7 HARI |
|
| 187 |
Gigi Palsu Permanen Metal Porcelain (PFM) |
2.500.000 |
| 188 |
Gigi Palsu Permanen / Veneer All Porcelain Emax |
3.500.000 |
| 189 |
Gigi Palsu Permanen / Veneer All Porcelain Zirconia |
4.000.000 |
| 190 |
|
|
| 191 |
KAWAT GIGI, ORTHODONTI atau BEHEL GIGI |
|
| 192 |
Behel Metal USA (1 Rahang) |
3.000.000 |
| 193 |
Behel Metal USA (2 Rahang) |
6.000.000 |
| 194 |
Behel Ceramic USA (1 Rahang) |
4.500.000 |
| 195 |
Behel Ceramic USA (2 Rahang) |
9.000.000 |
| 196 |
Behel Metal USA Mini (1 Rahang) |
3.750.000 |
| 197 |
Behel Metal USA Mini (2 Rahang) |
7.500.000 |
| 198 |
Behel Gigi Ceramic USA Mini (1 Rahang) |
4.750.000 |
| 199 |
Behel Gigi Ceramic USA Mini (2 Rahang) |
9.500.000 |
| 200 |
Behel Metal AO |
8.000.000 |
| 201 |
Behel Self Ligating |
10.000.000 |
| 202 |
Behel Self Ligating Clear |
15.000.000 |
| 203 |
Behel Self Ligating Damon 3M |
22.000.000 |
| 204 |
Behel Self Ligating Clear AO |
22.000.000 |
| 205 |
|
|
| 206 |
KONTROL BEHEL GIGI |
|
| 207 |
Kontrol Behel Metal / Ceramic (2 Rahang) |
210.000 |
| 208 |
Kontrol Behel Metal / Ceramic (1 Rahang) |
160.000 |
| 209 |
Lem Bracket (1 Bracket) |
65.000 |
| 210 |
Ganti Bracket Metal / Ceramic (1 Bracket) |
60.000 |
| 211 |
Kontrol Behel Self Lighting / Damon + Scaling Gigi |
385.000 |
| 212 |
Lem Bracket Self Lighting / Damon (1 Bracket) |
110.000 |
| 213 |
Ganti Bracket Self Lighting / Damon (1 Bracket) |
360.000 |
| 214 |
Post Bite Composite |
305.000 |
| 215 |
Post Bite GIC |
280.000 |
| 216 |
Lem Gic Ortho |
100.000 |
| 217 |
Karet Elastic |
25.000 |
| 218 |
Sikat Gigi Ortho |
30.000 |
| 219 |
Sikat Gigi Cemara Ortho |
15.000 |
| 220 |
Wax Ortho |
15.000 |
| 221 |
|
|
| 222 |
EXPRESS RETAINER GIGI - 1 HARI JADI |
|
| 223 |
Clear Retainer (2 Rahang) |
1.700.000 |
| 224 |
Clear Retainer (1 Rahang) |
1.250.000 |
| 225 |
|
|
| 226 |
RETAINER GIGI |
|
| 227 |
Hawley Retainer (2 Rahang) |
1.800.000 |
| 228 |
Hawley Retainer (1 Rahang) |
900.000 |
| 229 |
Clear Retainer (2 Rahang) |
1.400.000 |
| 230 |
Clear Retainer (1 Rahang) |
950.000 |
| 231 |
Lingual Retainer (1 Rahang) |
2.000.000 |
| 232 |
|
|
| 233 |
ORTHODONTI, KAWAT GIGI, atau BEHEL GIGI LEPASAN |
|
| 234 |
Ortho Lepasan (1 Rahang) |
775.000 |
| 235 |
Ortho Lepasan (2 Rahang) |
1.525.000 |
| 236 |
Kontrol Ortho Lepasan (1 Rahang) |
160.000 |
| 237 |
Kontrol Ortho Lepasan (2 Rahang) |
210.000 |
| 238 |
|
|
| 239 |
PAKET LEPAS BEHEL |
|
| 240 |
Lepas Behel, Bersihkan Lem (1 Rahang) |
300.000 |
| 241 |
Lepas Behel, Bersihkan Lem (2 Rahang) |
600.000 |
| 242 |
Lepas Behel, Bersihkan Lem & Karang Gigi (1 Rahang) |
500.000 |
| 243 |
Lepas Behel, Bersihkan Lem & Karang Gigi (2 Rahang) |
975.000 |
| 246 |
Lepas Behel, Bersihkan Lem & Karang Gigi, Retainer Clear (1 Rahang) |
1.560.000 |
| 247 |
Lepas Behel, Bersihkan Lem & Karang Gigi, Retainer Clear (2 Rahang) |
2.485.000 |
| 248 |
|
|
| 249 |
PINDAHAN KONTROL BEHEL atau PASIEN LUAR |
|
| 250 |
Kontrol Behel Metal (1 Rahang) |
210.000 |
| 251 |
Kontrol Behel Metal (2 Rahang) |
260.000 |
| 252 |
Lem Braket (1 Braket) |
115.000 |
| 253 |
Ganti Braket (1 Buah) |
110.000 |
| 254 |
Kontrol Behel Ceramic, Sapphire, Damon atau Empower Metal (1 Rahang) |
210.000 |
| 255 |
Kontrol Behel Ceramic, Sapphire, Damon atau Empower Metal (2 Rahang) |
260.000 |
| 256 |
Lem Bracket Ceramic, Sapphire, Damon atau Empower Metal (1 Bracket) |
115.000 |
| 257 |
Ganti Bracket Ceramic atau Sapphire (1 Bracket) |
250.000 |
| 258 |
Ganti Bracket Damon atau Empower Metal & Clear (1 Bracket) |
350.000 |
| 259 |
Lepas Behel, Bersihkan Lem (1 Rahang) |
300.000 |
| 260 |
Lepas Behel, Bersihkan Lem (2 Rahang) |
600.000 |
| 261 |
Ganti Kawat Orthodonti (1 Buah) |
30.000 |
| 262 |
Slicing Double Abrasif (1 Buah) |
30.000 |
| 263 |
Open Coil Spring (1 Buah) |
30.000 |
| 265 |
Bahan Lip Bumper (1 Buah) |
30.000 |
| 266 |
Lem Ring atau Mollar Band (1 Buah) |
280.000 |
| 267 |
|
|
| 268 |
MEMUTIHKAN GIGI atau BLEACHING GIGI DENGAN SINAR |
|
| 269 |
Bleaching Gigi |
1.700.000 |
| 270 |
Paket Bleaching Gigi, Scaling Gigi & Polising |
2.050.000 |
| 271 |
Paket Bleaching Gigi, Scaling Gigi & Protection |
3.500.000 |
| 272 |
|
|
| 273 |
SPLINTING atau MENGATASI GIGI GOYANG |
|
| 274 |
Splinting dengan Resin Komposit pergigi |
280.000 |
| 275 |
Splinting dengan Kombinasi Resin Komposit dan Kawat pergigi |
335.000 |
| 276 |
Splinting dengan Kombinasi Resin Komposit dan Fiber pergigi |
430.000 |
| 277 |
|
|
| 278 |
OBTURATOR |
|
| 279 |
Obturator Akrilik |
775.000 |
| 280 |
Obturator Kerangka Logam (Double Impression) |
2.225.000 |
| 281 |
Obturator Essix, Clear atau Transparan |
775.000 |