Biaya da

NO JENIS TINDAKAN TAHAP PEKERJAAN

Sebelum Pemeriksaan

1 Pemeriksaan Gigi

Pemeriksaan Objektive
Sterilisasi
Pemeriksaan Tekanan Darah

pemberian anastesi

jeda tunggu reaksi anastesi

2 Cabut Gigi Posterior 1 Gigi

pencabutan gigi
pemeriksaan sisa gigi yang di cabut
Pemeriksaan Gigi
Pemeriksaan Tekanan Darah
pemberian anastesi
jeda tunggu reaksi anastesi

3 Cabut Gigi Anterior 1 Gigi pencabutan gigi

pemeriksaan sisa gigi yang di cabut

Sterilisasi
Pemeriksaan Gigi
pemberian anastesi
jeda tunggu reaksi anastesi

4 Cabut Gigi Susu 1 Gigi

pemeriksaan sisa gigi yang di cabut
4 Cabut Gigi Susu 1 Gigi

Sterilisasi
Pemeriksaan Gigi
Pemeriksaan Tekanan Darah
pemberian anastesi

5 Cabut Gigi Sulit jeda tunggu reaksi anastesi

pencabutan gigi
pemeriksaan sisa gigi yang di cabut
Sterilisasi
Pemeriksaan Gigi
Preparasi Kavitas
Medikamentosa

6 Endodontic 1 Visite

Tambalan Voco
Polishing & Finishing

Pemeriksaan Gigi
isolasi daerah kerja

7 Perawatan abses gigi external

Pemeriksaan Gigi
isolasi daerah kerja

8 Perawatan abses gigi internal

8 Perawatan abses gigi internal

Pemeriksaan Gigi
isolasi daerah kerja

9 Trepanasi / Insisi Abses

Pemeriksaan Gigi
isolasi daerah kerja
10 Kuret ( Pocket Periodontal )
Pemeriksaan Gigi

preparasi
11 Bongkar Tambalan
Pemeriksaan Gigi

Membersihkan Karang Gigi

12
@RA @RB
Pemeriksaan Gigi

13 Overkulektomi

Pemeriksaan Gigi

14 Pengambilan Epulis
Pemeriksaan Gigi
Perawatan Saluran Akar :
a. Kunjungan I
Pemeriksaan Gigi
b. Kunjungan II dan
15 seterusnya
Pemeriksaan Gigi
c. Pengisian
Saluran Akar
Pemeriksaan Gigi

16 Proteksi
Pemeriksaan Gigi
17 Reposisi Rahang
Pemeriksaan Gigi
Tambal Sinar Kecil 1 Gigi Preparasi Kavitas
Penambalan Sinar

18

Polishing & Finishing

Pemeriksaan Gigi
Tambal Sinar Besar 1 Gigi Preparasi Kavitas
Penambalan Sinar

19

Polishing & Finishing

Pemeriksaan Gigi

Tambal Fuji 1 Gigi lubang kecil Preparasi Kavitas

20
penambalan GIC (fuji)

Pemeriksaan Gigi
Tambal Fuji 1 Gigi lubang
Preparasi Kavitas
besar

21 penambalan GIC (fuji)

21

Pemeriksaan Gigi
Tambal Sementara dengan
pemberian edikamen
Eugenol 1 Gigi

22

tambalan sementara
Pemeriksaan Gigi
Tambal Sementara dengan
pemberian edikamen
CHKM 1 Gigi

23

tambalan sementara
Pemeriksaan Gigi
Tambal Sementara dengan
pemberian edikamen
Cresopen 1 Gigi

24

tambalan sementara
Pemeriksaan Gigi
 Biaya dan Estimasi Tindakan Poli Gigi 2022
PERKIRAAN
PERKIRAAN BHP
ALAT/BAHAN BIAYA BHP (1 set Total BHP/Pasien
PERPASIEN
pembelian)
Celemek Rp35,000.00 Rp1,000.00
Glove Serenity Rp4,000.00 Rp4,800.00
Obat Kumur Rp5,000.00 Rp-
Rp7,400.00
masker Rp20,000.00 Rp600.00
1 Set alat standar Rp-
Baycline Rp8,000.00 Rp1,000.00
Tensi Meter Rp-
syringe dan Pehacain/lidocain
Rp10,000.00 Rp10,000.00

kasa Rp5,000.00 Rp1,000.00 Rp18,400.00

masker Rp20,000.00 Rp600.00
Bein dan Tang Rp-
1 set alat standar Rp-
Rp6,800.00
Tensi Meter Rp-
syringe dan Pehacain/lidocain Rp10,000.00 Rp10,000.00
masker Rp20,000.00 Rp600.00
kasa Rp5,000.00 Rp1,000.00
Bein dan Tang Rp- Rp19,000.00
masker Rp20,000.00 Rp600.00
1 set alat standar Rp-
alkohol Rp-
Rp6,800.00
syringe dan Pehacain/lidocain Rp10,000.00 Rp10,000.00

kasa Rp5,000.00 Rp1,000.00

masker Rp20,000.00 Rp600.00 Rp18,400.00
1 Set alat standar Rp-
 Rp18,400.00

alkohol Rp-
Rp6,800.00
Tensi Meter Rp-
syringe dan Pehacain/lidocain Rp10,000.00 Rp10,000.00
masker Rp20,000.00 Rp600.00
kasa Rp5,000.00 Rp1,000.00
Rp18,400.00
Bein dan Tang Rp-
1 set alat standar Rp-
alkohol Rp-
Rp6,800.00
Diamond bur set dewasa Rp50,000.00 Rp2,000.00
Calcyl metapex Rp180,000.00 Rp9,000.00
calcyl plus + iodoform Rp100,000.00 Rp5,000.00
kasa Rp5,000.00 Rp1,000.00
LC cal Rp200,000.00 Rp10,000.00
Lining GIC Rp150,000.00 Rp1,500.00
masker Rp20,000.00 Rp600.00 Rp65,250.00
Caviton GC (Tambalan
Sementara) Rp55,000.00 Rp550.00
A1 Rp335,000.00 Rp22,000.00
Bur Poles Set Rp5,000.00 Rp200.00
Bur eve Rp150,000.00 Rp5,000.00
Artikulating Paper Rp50,000.00 Rp1,600.00
Rp6,800.00
eugenol Rp27,500.00 Rp600.00
cotton pellet Rp- Rp-
kasa Rp5,000.00 Rp1,000.00
Rp9,500.00
masker Rp20,000.00 Rp600.00
providon iodin Rp20,000.00 Rp500.00
Rp6,800.00
eugenol Rp27,500.00 Rp600.00
cotton pellet Rp- Rp-
kasa Rp5,000.00 Rp1,000.00

Rp9,500.00
masker Rp20,000.00 Rp600.00
providon iodin Rp20,000.00 Rp500.00
Rp6,800.00 Rp9,500.00
eugenol Rp27,500.00 Rp600.00
kasa Rp5,000.00 Rp1,000.00
masker Rp20,000.00 Rp600.00
Rp9,500.00
cotton pellet Rp- Rp-
providon iodin Rp20,000.00 Rp500.00
Rp6,800.00
providon iodin Rp20,000.00 Rp1,000.00
Rp7,800.00
Rp6,800.00
Diamond bur set dewasa
Rp50,000.00 Rp2,000.00 Rp8,800.00
Rp6,800.00
scaller elektrik
Rp- Rp-
masker Rp7,400.00
Rp20,000.00 Rp600.00
Rp6,800.00
blade no 14 Rp40,000.00 Rp5,000.00
kasa Rp5,000.00 Rp1,000.00
Rp13,400.00
masker Rp20,000.00 Rp600.00
Rp6,800.00
blade no 14 Rp40,000.00 Rp5,000.00
Rp11,800.00
Rp6,800.00

eugenol Rp20,000.00 Rp1,000.00

Rp7,800.00
Rp6,800.00
chkm
Rp20,000.00 Rp1,000.00 Rp7,800.00
Rp6,800.00
zinc phospate cement
Rp100,000.00 Rp6,000.00 Rp12,800.00
Rp6,800.00

Rp6,800.00
Rp6,800.00
 Rp- Rp-
Rp6,800.00
Rp6,800.00
Diamond bur set dewasa Rp50,000.00 Rp2,000.00
Etsa Rp104,000.00 Rp3,000.00
Bonding Medental Rp116,000.00 Rp3,000.00
Mikrobrush Rp25,000.00 Rp1,000.00
masker Rp20,000.00 Rp600.00
Rp49,400.00
Tambalan polofil
A1 Rp335,000.00 Rp25,000.00
Bur poles Rp50,000.00 Rp2,000.00
bur eve Rp150,000.00 Rp6,000.00
Rp6,800.00
Diamond bur set dewasa Rp50,000.00 Rp2,000.00
Etsa Rp104,000.00 Rp3,000.00
Bonding Medental Rp116,000.00 Rp3,000.00

Mikrobrush Rp25,000.00 Rp1,000.00

masker Rp20,000.00 Rp600.00 Rp49,400.00
Tambalan polofil
A1 Rp335,000.00 Rp25,000.00
Bur poles Rp50,000.00 Rp2,000.00
bur eve Rp150,000.00 Rp6,000.00
Rp6,800.00
Diamond bur set dewasa
Rp50,000.00 Rp2,000.00

masker Rp20,000.00 Rp600.00 Rp15,400.00

Dentin Conditioner Rp120,000.00 Rp2,000.00
GIC 3m Rp300,000.00 Rp4,000.00
Rp6,800.00
Diamond bur set dewasa
Rp50,000.00 Rp2,000.00
masker Rp20,000.00 Rp600.00
Dentin Conditioner Rp120,000.00 Rp2,000.00 Rp15,400.00
 Rp15,400.00
GIC 3m Rp300,000.00 Rp4,000.00
Rp6,800.00
cotton pellet
Rp- Rp-
masker Rp20,000.00 Rp600.00
Eugenol Rp27,500.00 Rp1,000.00 Rp9,400.00
caviton Rp55,000.00 Rp1,000.00
Rp6,800.00
cotton pellet
Rp- Rp-
masker Rp20,000.00 Rp600.00
CHKM Rp30,000.00 Rp1,000.00 Rp9,400.00
caviton Rp55,000.00 Rp1,000.00
Rp6,800.00
cotton pellet
Rp- Rp-
masker Rp20,000.00 Rp600.00
Cresopen Rp40,000.00 Rp1,000.00 Rp9,400.00
caviton Rp55,000.00 Rp1,000.00
Rp6,800.00
2022
TARIF TINDAKAN KEUNTUNGAN ESTIMASI WAKTU
SAAT INI PERPASIEN PENGERJAAN

Rp35,000.00 Rp27,600.00 ≤ 5 menit

Rp87,000.00 Rp68,600.00 ≤ 30 menit

Rp65,000.00 Rp46,000.00 ≤ 30 menit

Rp44,000.00 Rp25,600.00 ≤ 10 menit

Rp44,000.00 Rp25,600.00 ≤ 10 menit

Rp143,000.00 Rp124,600.00 ≤ 1 jam

Rp78,000.00 Rp12,750.00 ≤ 30 menit

Rp44,000.00 Rp34,500.00 ≤ 25 menit

Rp54,000.00 Rp44,500.00 ≤ 25 menit

Rp54,000.00 Rp44,500.00 ≤ 25 menit

Rp49,000.00 Rp39,500.00 ≤ 25 menit

Rp54,000.00 Rp46,200.00 ≤ 20 menit

Rp39,000.00 Rp30,200.00 ≤ 15 menit

Rp66,000.00 Rp58,600.00 ≤ 1 jam

Rp53,000.00 Rp39,600.00 ≤ 30 menit

Rp163,000.00 Rp151,200.00 ≤ 20 menit

Rp55,000.00 Rp47,200.00 ≤ 25 menit

Rp53,000.00 Rp45,200.00 ≤ 25 menit

Rp53,000.00 Rp40,200.00 ≤ 30 menit

Rp52,000.00 Rp45,200.00 ≤ 30 menit

Rp116,000.00 Rp109,200.00 ≤ 1 jam

Rp98,000.00 Rp48,600.00 ≤ 30 menit

Rp132,000.00 Rp82,600.00 ≤ 1 jam

Rp47,000.00 Rp31,600.00 ≤ 25 menit

Rp66,000.00 Rp50,600.00 ≤ 30 menit

Rp66,000.00 Rp50,600.00 ≤ 30 menit

Rp46,000.00 Rp36,600.00 ≤ 15 menit

Rp46,000.00 Rp36,600.00 ≤ 15 menit

Rp46,000.00 Rp36,600.00 ≤ 15 menit

 REKOMENDASI
TARIF TINDAKAN NHDC
TARIF POLI GIGI

Rp35,000.00

Rp350,000.00 Rp150,000.00

Rp350,000.00 Rp100,000.00

Rp150,000.00 Rp70,000.00
Rp150,000.00 Rp70,000.00

Rp500,000.00 Rp200,000.00

Rp1,500,000.00 Rp200,000.00

Rp350,000.00 Rp100,000.00

Rp350,000.00 Rp100,000.00
 Rp350,000.00 Rp100,000.00

Rp350,000.00 Rp100,000.00

Rp350.000,00 - Rp 500.000,00 Rp200,000.00

Rp400,000.00 Rp100,000.00

Rp430,000.00 Rp150,000.00

Rp350,000.00 Rp100,000.00

Rp500,000.00 Rp150,000.00
Rp350,000.00 Rp150,000.00

Rp500,000.00 Rp200,000.00

Rp250,000.00 Rp100,000.00

Rp300,000.00 Rp150,000.00
Rp300,000.00 Rp150,000.00

Rp100,000.00

Rp100,000.00

Rp100,000.00