| TARIF PENGOBATAN POLIKLINIK GIGI | |||
| NO | JENIS PELAYANAN | HARGA | |
| 1 | Konsultasi | 10,000 | / Kunjungan |
| Visite pasien opname | 20,000 | / Kunjungan | |
| 2 | Pertolongan kecil | ||
| A.Grinding, polishing | 30,000 | / elemen | |
| C.Rontgen Foto (RO) | 20,000 | / film | |
| 3 | Konservasi | ||
| Tumpatan sementara (EF) | 25,000 | / kavitas | |
| Tumpatan Amalgam (AF) | 40,000 | / kavitas | |
| Tumpatan Light Cure (LC) | 70,000 | / kavitas | |
| Fissure Sealant dengan LC (FS) | 50,000 | / kavitas | |
| Jacket Crown | |||
| Jacket Crown Akrilik (JA) | 300,000 | / elemen | |
| Jacket Crown Porcelain | 500,000 | / elemen | |
| Dowel Crown | |||
| Dowel Crown Mahkota Akrilik (JA) | 350,000 | / elemen | |
| Dowel Crown Mahkota Porcelain | 550,000 | / elemen | |
| Pulp Capping | 25,000 | / kavitas | |
| Perawatan saluran akar non vital | 25,000 | / Kunjungan | |
| Perawatan saluran akar vital (amputan vital kunjungan pertama) | 40,000 | / Kunjungan | |
| Pengisian saluran akar | 45,000 | / saluran akar | |
| 4 | Peridonsia | ||
| Scalling ( RA & RB ) | 50,000 | / Kunjungan | |
| Bleeching | 20,000 | / rahang | |
| Ginggivectomy, Ginggivoplasty, Flap Operation | 100,000 | / regio | |
| 5 | Oral Surgery : | ||
| Ekstraksi gigi dicidui (Exod) | |||
| A.Dengan Chlor Ethyl | 25,000 | / elemen | |
| B.Dengan Injectio | 35,000 | / elemen | |
| Ekstraksi gigi permanen (Exop) | 40,000 | / elemen | |
| Hecting / suturing pasca exo (H) | 20,000 | / hecting | |
| Minor Surgery : | |||
| Perawatan Abses/Incisi Abses | 75,000 | / regio | |
| Pengambilan Fraktur Radix | 60,000 | / elemen | |
| Perawatan dry socket/post exo trauma | 60,000 | / elemen | |
| Perawatan pendarahan pasca exo | 30,000 | / elemen | |
| Odontectomy (Impaksi) | 500,000 | / elemen | |
| Alveiolectomy | 150,000 | / elemen | |
| Ekstirpasi Mucocele, Ranula Cyst, Tumor | 150,000 | s/d 350.000 | |
| Epexreseksi, Apicovectomy, Curetase Granul | 150,000 | s/d 350.000 | |
| Preprosthetic Surgery (Vext Ibuloplasty) | 150,000 | s/d 350.000 | |
| Penutupan Perforasi Sinus Maksilaris | 150,000 | s/d 350.000 | |
| 6 | Prosthodensia : | ||
| A. Removable | |||
| GTS ( 1 gigi + palt akrilik transpara ) (GTSt) | 150,000 | / rahang | |
| Tambahan 1 Gigi | 60,000 | / gigi | |
| GTS ( 1 gigi + frame dentur) | 500,000 | / rahang | |
| GTL (Transparan) | 800,000 | / rahang | |
| GTL (Frame dentur) | 2,500,000 | / rahang | |
| Reparasiprothesa | 100,000 | / plat | |
| B. Fixed | |||
| Bridge Metal | 300,000 | / elemen | |
| Bridge Porcelain | 500,000 | / elemen | |
| 7 | Orthodhonsia | ||
| Removable Ortho | 400,000 | / rahang | |
| Space Maintaner | 200,000 | / rahang | |
| Space Regainer | 350,000 | / rahang | |
| Plat Espansi | 400,000 | / rahang | |