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KODE TINDAKAN BIAYA BIAYA

PELAYANAN MEDIS BAHAN/LAB


UM 1 Konsultasi 50,000 0
UM 2 Cetak alginate 150,000 20,000
UM 3 Cetak double impression 250,000 50,000
UM 4 Anestesi / ampul / carpul 30,000 30,000
UM 5 Protection + vitamin 100,000 50,000

PR 1 Scaling klas 1 150,000 20,000


PR 2 Scaling klas 2 200,000 20,000
PR 3 Scaling klas 3 250,000 20,000
PR 4 Kuretase (per gigi) 75,000 20,000
PR 5 Gingivectomi/ gingivoplasty (per gigi) 100,000 35,000
PR 6 Scaling premium (protection + vit) klas 1 220,000 70,000
PR 7 Scaling premium (protection+vit) klas 2 270,000 70,000
PR 8 Scaling premium (protection+vit) klas 3 300,000 70,000
PR9 Splinting / gigi 100,000 35,000

TS (cavit/eugenol fletcher) dan atau + eugenol/


KO 1 100,000 15,000
pulperyl/ CHKM/ devital dan bongkar tambalan

KO 2 Tambalan GIC kecil 120,000 20,000


KO 3 Tambalan GIC besar 180,000 30,000
KO 4 Tambalan sinar kecil (IP/ flow) 200,000 25,000
KO 5 Tambalan sinar besar 250,000 35,000
KO 6 Pulp caping + TS 100,000 20,000
KO 7 Pulp caping + GIC kecil 200,000 30,000
KO 8 Pulp caping + GIC besar 230,000 40,000
KO 9 Pulp caping + LC kecil 250,000 35,000
KO 10 Pulp caping + LC besar 300,000 45,000

EN 1 Open bur + R/F + obat + TS tunggal 150,000 20,000


EN 2 Open bur + R/F + obat + TS ganda 200,000 30,000
EN 3 Ganti obat (tunggal / ganda) 100,000 15,000
EN 4 Obturasi tunggal 150,000 35,000
EN 5 Obturasi ganda 250,000 50,000
EN 6 Paket endo tunggal (all in) 550,000 150,000
EN 7 Paket endo ganda (all in) 850,000 170,000

OS 1 Pencabutan gigi anak + CE 100,000 10,000


OS 2 Pencabutan gigi anak + infil 130,000 30,000
OS 3 Pencabutan gigi dewasa GR / goyang 150,000 35,000
OS 4 Pencabutan gigi dewasa GP 200,000 35,000
OS 5 Pencabutan komplikasi 250,000 50,000
OS 6 Dry socket 100,000 20,000
OS 7 Insisi abses / drainase 100,000 20,000
OS 8 Hecting / jahitan 50,000 10,000
OS 9 Buka jahitan 100,000 10,000
OS 10 Batal pencabutan sudah anestesi 75,000 35,000

OD 1 Odontectomy klas 1 1,500,000 250,000


OD 2 Odontectomy klas 2 2,000,000 350,000
OD 3 Alveolectomy 350,000 50,000
OD 4 Operculectomy 300,000 50,000

FD 1 Full denture RA + RB 5,000,000 1600000


FD 2 Full denture RA / RB 3,000,000 800000

RD 1 Plat akrilik 850,000 250000


RD 2 Per gigi plat akrilik 125,000 75000
RD 3 Plat flexi / valplas 1,000,000 350000
RD 4 Per gigi plat flexi / valplas 150,000 75000
RD 5 Plat thermosens 1,500,000 450000
RD 6 Per gigi plat thermosens 200,000 75000
RD 7 Reparasi plat patah / plat 350,000 175000
RD 8 Rebaising / plat 450,000 200000

GC 1 Jacket crown acrylic 1,500,000 300000


GC 2 Bridge acrylic 4,000,000 900000
GC 3 Jacket crown porcelen 2,000,000 400000
GC 4 Bridge porcelen 5,000,000 550000
GC 5 Pasak / pin crown (+PSA) 2,000,000 700000
GC 6 Crown sementara 200,000 80000
GC 7 Sementasi ulang gigi tiruan 200,000 50000

OR 1 Removable orthodonti RA + RB 2,000,000 600000


OR 2 Removable orthodonti RA / RB 1,500,000 300000
OR 3 Kontrol removable orthodonti 150,000 15,000
OR 4 Reparasi plat removable orthodonti / plat 400,000 200000
OR 5 Fixed orthodonti metal RA + RB 4,500,000 900,000
OR 6 Fixed orthodonti metal RA / RB 3,000,000 750,000
OR 7 Fixed orthodonti ceramic RA + RB 6,000,000 1,200,000
OR 8 Fixed orthodonti ceramic RA / RB 3,500,000 1,050,000
OR 9 Fixed orthodonti metal premium RA + RB 6,500,000 1,300,000
OR 10 Fixed orthodonti metal premium RA / RB 4,000,000 1,150,000
OR 11 Kontrol fixed orthodonti 200,000 50,000
OR 12 Breket lepas (sementasi ulang) / pcs 30000 10,000

OR 13 Breket hilang metal/ceramic/bucal tube per pcs 100,000 35,000

OR 14 Breket hilang metal premium 135,000 50,000


OR 15 Ganti wire per pcs 75,000 40,000
OR 16 OCS / CCS / botton per pcs 100,000 40,000
OR 17 Pindah control 1,000,000 250,000
OR 18 Lepas breket 800,000 150,000
OR 19 removable retainer (hawley/clear) 1,000,000 300000
OR 20 Fixed retainer 1,200,000 250000

ES 1 Bleaching RA + RB 2,500,000 100000


ES 2 Bleaching RA / RB 1,500,000 600000
ES 3 Veneer komposit / gigi 450,000 80,000
ES 4 Veneer porcelen / unit 3,500,000 400000
ES 5 Veneer emax / unit 4,000,000 1200000
ES 6 Veneer zirconia / unit 4,500,000 1500000
ES 7 Diamond smile / pcs 200,000 75,000
BIAYA JASA DOKTER FEE KLINIK KEUNTUNGAN klinik dokter
JASA 40% 25% 25% 40%
50,000 20,000 12,500 17,500
130,000 60,000 32,500 37,500 37500 60000
200,000 100,000 50,000 50,000 62500 100000
0 0 0 0
50,000 40,000 12,000 -2,000 25000 40000
0 0 0 0
130,000 60,000 32,500 37,500 37500 60000
180,000 80,000 45,000 55,000 50000 80000
230,000 100,000 57,500 72,500 62500 100000
55,000 30,000 13,750 11,250 18750 30000
65,000 40,000 16,250 8,750 25000 40000
150,000 88,000 37,500 24,500 55000 88000
200,000 108,000 50,000 42,000 67500 108000
230,000 120,000 57,500 52,500 75000 120000
65,000 40,000 16,250 8,750 25000 40000
0 0 0 0

85,000 40,000 21,250


23,750 25000 40000
100,000 48,000 25,000 27,000 30000 48000
150,000 72,000 37,500 40,500 45000 72000
175,000 80,000 43,750 51,250 50000 80000
215,000 100,000 53,750 61,250 62500 100000
80,000 40,000 20,000 20,000 25000 40000
170,000 80,000 42,500 47,500 50000 80000
190,000 92,000 47,500 50,500 57500 92000
215,000 100,000 53,750 61,250 62500 100000
255,000 120,000 63,750 71,250 75000 120000
0 0 0 0
130,000 60,000 32,500 37,500 37500 60000
170,000 80,000 42,500 47,500 50000 80000
85,000 40,000 21,250 23,750 25000 40000
115,000 60,000 28,750 26,250 37500 60000
200,000 100,000 50,000 50,000 62500 100000
400,000 220,000 100,000 80,000 137500 220000
680,000 340,000 170,000 170,000 212500 340000
0 0 0 0
90,000 40,000 22,500 27,500 25000 40000
100,000 52,000 25,000 23,000 32500 52000
115,000 60,000 28,750 26,250 37500 60000
165,000 80,000 41,250 43,750 50000 80000
200,000 100,000 50,000 50,000 62500 100000
80,000 40,000 20,000 20,000 25000 40000
80,000 40,000 20,000 20,000 25000 40000
40,000 20,000 10,000 10,000 12500 20000
90,000 40,000 22,500 27,500 25000 40000
40,000 30,000 10,000 0 18750 30000
0 0 0 0
1,250,000 600,000 312,500 337,500 375000 600000
1,650,000 800,000 412,500 437,500 500000 800000
300,000 140,000 75,000 85,000 87500 140000
250,000 120,000 62,500 67,500 75000 120000
0 0 0 0
3,400,000 2,000,000 850,000 550,000
2,200,000 1,200,000 550,000 450,000
0 0
600,000 340,000 150,000 110,000
50,000 50,000 12,500 -12,500
650,000 400,000 162,500 87,500
75,000 60,000 18,750 -3,750
1,050,000 600,000 262,500 187,500
125,000 80,000 31,250 13,750
175,000 160,000 43,750 -28,750
250,000 200,000 62,500 -12,500
0 0
1,200,000 600,000 300,000 300,000
3,100,000 1,600,000 775,000 725,000
1,600,000 800,000 400,000 400,000
4,450,000 2,000,000 1,112,500 1,337,500
1,300,000 800,000 325,000 175,000
120,000 80,000 30,000 10,000
150,000 80,000 37,500 32,500
0 0
1,400,000 800,000 350,000 250,000
1,200,000 600,000 300,000 300,000
135,000 60,000 33,750 41,250
200,000 160,000 50,000 -10,000
3,600,000 1,800,000 900,000 900,000
2,250,000 1,200,000 562,500 487,500
4,800,000 2,400,000 1,200,000 1,200,000
2,450,000 1,400,000 612,500 437,500
5,200,000 2,600,000 1,300,000 1,300,000
2,850,000 1,600,000 712,500 537,500
150,000 80,000 37,500 32,500
20,000 10,000 5,000 5,000
65,000
40,000 16,250 8,750
85,000 54,000 21,250 9,750
35,000 20,000 8,750 6,250
60,000 40,000 15,000 5,000
750,000 400,000 187,500 162,500
650,000 320,000 162,500 167,500
700,000 400,000 175,000 125,000
950,000 480,000 237,500 232,500
0 0
2,400,000 1,000,000 600,000 800,000
900,000 600,000 225,000 75,000
370,000 180,000 92,500 97,500
3,100,000 1,400,000 775,000 925,000
2,800,000 1,600,000 700,000 500,000
3,000,000 1,800,000 750,000 450,000
125,000 80,000 31,250 13,750
sisa bersih selisih
c-j-k L-D H-M

52,500 32,500 5,000


87,500 37,500 12,500
0
35,000 -15,000 13,000
0 0 0
52,500 32,500 5,000
70,000 50,000 5,000
87,500 67,500 5,000
26,250 6,250 5,000
35,000 0 8,750
77,000 7,000 17,500
94,500 24,500 17,500
105,000 35,000 17,500
35,000 0 8,750
0 0 0

35,000 20,000 3,750


42,000 22,000 5,000
63,000 33,000 7,500
70,000 45,000 6,250
87,500 52,500 8,750
35,000 15,000 5,000
70,000 40,000 7,500
80,500 40,500 10,000
87,500 52,500 8,750
105,000 60,000 11,250
0 0 0
52,500 32,500 5,000
70,000 40,000 7,500
35,000 20,000 3,750
52,500 17,500 8,750
87,500 37,500 12,500
192,500 42,500 37,500
297,500 127,500 42,500
0 0 0
35,000 25,000 2,500
45,500 15,500 7,500
52,500 17,500 8,750
70,000 35,000 8,750
87,500 37,500 12,500
35,000 15,000 5,000
35,000 15,000 5,000
17,500 7,500 2,500
35,000 25,000 2,500
26,250 -8,750 8,750
0 0 0
525,000 275,000 62,500
700,000 350,000 87,500
122,500 72,500 12,500
105,000 55,000 12,500
0 0