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POLI MADYA PKG ADITYAWARMAN

DIVISI KONSERVASI
1 RMGIC/MRGIC 255,000
2 Apeks reseksi 780,000
3 Band gigi fraktur 300,000
4 Cetak Alginate 263,000
5 Cetak Double Impression 375,000
6 Composite besar 483,000
7 Composite kecil 435,000
8 GIC 255,000
9 Home bleaching* 1,500,000
10 In office bleaching* 2,250,000
11 Inlay / Onlay* 1,290,000
12 Konsultasi 135,000
13 Kontrol 143,000
14 labial veneer direk 900,000
15 labial veneer indirek* 1,500,000
16 Mahkota all porcelain* 1,800,000
17 Mahkota Metal* 1,350,000
18 Mahkota Sementara * 278,000
19 Pengisian 1 saluran akar 300,000
20 Pengisian 2 saluran akar 330,000
21 Pengisian 3 saluran akar/lebih 360,000
22 Pin Casting* 480,000
23 Pin ready made fiber 1,050,000
24 Pit and Fissure Sealent 300,000
25 Premidiksi 143,000
26 PSA 1 saluran akar 285,000
27 PSA 2 saluran akar 375,000
28 PSA 3 saluran akar/lebih 390,000
29 Pulp Capping 240,000
30 Tambalan Sementara 240,000
31 Bleaching Internal* 459,000
32 mocking* 300,000
33 Topical Fluor Application 270,000

DIVISI BEDAH MULUT

1 Alveolektomi/ Reg 713,000
2 Apeksreseksi 780,000
3 buka fiksasi/archbar 645,000
4 Buka Jahitan 195,000
5 Dibridement 660,000
6 Eksisi Tumor Jinak 750,000
7 Enukleasi Kista 1,350,000
8 Incisi Abses 330,000
9 Incisi Biopsi 525,000
10 Inj. Scler Agent 450,000
11 Konsultasi 135,000
12 Kontrol 143,000
13 OD M3 IMP KL I 2,136,000
14 OD M3 IMP KL II 2,580,000
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POLI MADYA PKG ADITYAWARMAN

15 OD M3 IMP KL III 2,895,000
16 Operkulektomi 330,000
17 Pencabutan Gigi 375,000
18 Pencabutan Gigi dengan Komplikasi 600,000
19 Rep Fix dg Archbar (RA + RB) 2,550,000
20 Rep Fix dg Archbar(1 Rahang) 1,500,000
21 Reposisi Disl TMJ 750,000
22 Windowing Exp 900,000
23 Dental Implant 11,000,000

DIVISI PEDODONTI
1 Aktivasi Plat Aktif Sedang 240,000
2 RMGIC/MRGIC 255,000
3 Cetak Alginate 263,000
4 Cetak Double Impression 375,000
5 composite besar 480,000
6 Composite Kecil 435,000
7 Excisi mucocele 750,000
8 Feeding Plate 900,000
9 GIC 255,000
10 Incisi/cauterisasi 330,000
11 Inlay / Onlay* 1,290,000
12 Konsultasi 135,000
13 Kontrol 143,000
14 Kontrol Alat Lepasan 225,000
15 Mahkota all porcelain * 1,800,000
16 Mahkota Metal* 1,350,000
17 Mahkota Sementara * 278,000
18 Naso Alveolar Molding 2,511,000
19 Oral profilaksis/DHE 300,000
20 Ortho removable RA + RB 2,048,000
21 Penambahan Element* 330,000
22 Pencabutan dengan Komplikasi 600,000
23 Pencabutan dengan Suntik 375,000
24 Pencabutan Tanpa Suntik 210,000
25 Pengisian 1 saluran akar 300,000
26 Pengisian 2 saluran akar 330,000
27 Pengisian 3 saluran akar/lebih 360,000
28 Perawatan Plat Aktif Sedang RA/ RB saja* 2,048,000
29 Pin Casting* 480,000
30 Pin ready made metal 825,000
31 Pit and Fissure Sealant 300,000
32 Premedikasi 143,000
33 PSA 1 saluran akar 285,000
34 PSA 2 saluran akar 375,000
35 PSA 3 saluran akar/lebih 390,000
36 Pulp Capping 240,000
37 Reparasi Ringan : Reparasi Kawat* 323,000
38 Reparasi Ringan : Reparasi Patah* 338,000
39 Space mantainer removable 1 gigi 900,000
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POLI MADYA PKG ADITYAWARMAN

40 Tambalan Sementara 240,000
41 Kontrol NAM 240,000

DIVISI ORTHODONTI
1 Aktivator 4,350,000
2 Alat Cekat Metal RA dan RB 11,010,000
3 Alat Cekat Metal RA dan RB komplek 13,260,000
4 Alat Cekat Metal RA/ RB saja 6,405,000
5 Analisa 169,000
6 Cetak ortho + model kerja 308,000
7 ChinCup 2,205,000
8 Debonding/ Slicing 293,000
9 Face Mask 4,650,000
10 Facebow Transfer 480,000
11 Fixed Retainer RA & RB 4,482,000
12 Fixed Retainer RA / RB Saja 2,615,000
13 Foto Slide 206,000
14 Ganti Band Baru 300,000
15 Ganti Bracket Baru 240,000
16 Ganti Kawat Baru 255,000
17 Head Gear 2,535,000
18 Karet Intra Oral 150,000
19 Konsultasi 135,000
20 Kontrol Alat Cekat 240,000
21 Kontrol Alat Lepasan 225,000
22 Kontrol Retainer 210,000
23 Naso Alveolar Molding 2,511,000
24 Paper Surgery 168,000
25 Pasang Band Lepas 180,000
26 Pasang Bracket Lepas 225,000
27 Plat Removable Aktif Ringan RA/ RB saja 2,402,000
28 Plat Removable Aktif Sedang RA/ RB saja 2,402,000
29 Post Biter Plat 1,088,000
30 Posterior Bite Riser DG Tambalan 497,000
31 Quad Helix 1,988,000
32 Rapid Palatal Expantion 2,412,000
33 Removable Retainer RA dan RB 1,916,000
34 Removable Retainer RA/ RB saja 1,061,000
35 Separasi 245,000
36 Surgical Wafer Splint (1 Splint) 2,703,000
37 Temporary Anchorage 2,598,000
38 Topical Fluor Application 270,000
39 Trans Palatal Arch 2,325,000
40 Kontrol NAM 240,000

DIVISI PROSTHODONTI
1 Bongkar Crown/ unit 540,000
2 Bongkar Pin 540,000
Bongkar Protesa/ unit Gigi Tiruan sebagai
3 Lepasan 1,020,000
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POLI MADYA PKG ADITYAWARMAN

4 Cetak Alginate 263,000
5 Cetak Double Impression 375,000
6 Flexi Denture * 1,125,000
7 Full Denture (RA dan RB)* 3,000,000
8 GTS Frame* 1,185,000
9 Inlay / Onlay* 1,290,000
10 Konsultasi 135,000
11 Kontrol Prothesa 330,000
12 Mahkota all porcelain / Bridge * 1,800,000
13 Mahkota Metal* 1,350,000
14 Mahkota Sementara* 278,000
15 Obturator* 795,000
16 Occlusal Splint* 525,000
17 Penambahan Element* 330,000
18 Penambahan Wing* 390,000
19 Pin Casting* 480,000
20 Pin ready made metal 825,000
21 Plat Prothesa* 600,000
22 Reline/ Rebase : Soft Liner* 473,000
23 Reparasi Komplek : Reline/ Rebase* 446,000
24 Reparasi Ringan : Reparasi Kawat* 323,000
25 Reparasi Ringan : Reparasi Patah* 338,000
26 Sementasi Ulang 503,000
27 Single Denture (RA/ RB-1 rgh)* 1,463,000

DIVISI ORAL DIAGNOSTIK

1 Konsultasi 135,000

DIVISI PERIODONTI
1 Kontrol 143,000
2 Oclusal Adjustmen (OA) 345,000
3 SK 1 Kuadran 308,000
4 SK 2 Kuadran 345,000
5 SK 3 Kuadran 420,000
6 SK 4 Kuadran 495,000
7 Kuret per Gigi 420,000
8 Splinting Per Gigi 600,000
9 Gingivextomy/ Frenectomy 1,170,000
10 Operasi Flap/ Bone Graft 1,170,000
11 Ablatio Ginggiva & Amnion 1,101,000
12 Bone Graft 1,170,000

DIVISI PENYAKIT MULUT

1 Konsultasi 135,000
2 Kontrol/ kasus penyakit mulut 245,000
3 Premedikasi / kasus infeksi 248,000

DIVISI RONTGEN
1 Dental Foto 128,000
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POLI MADYA PKG ADITYAWARMAN

2 Panoramic 195,000
3 Chepalo 195,000