| NO. | JENIS PERAWATAN | HARGA TARIF | HARGA SPESIAL |
| (DISC 10%) | |||
| 1 | DENTAL SPECIALISTS | ||
| Administrasi | 100,000 | ||
| Konsultasi Dental GP | 250,000 | ||
| Konsultasi Dental Spesialis | 300,000 | ||
| Kontrol Dental GP | 175,000 | ||
| Kontrol Dental Spesialis | 225,000 | ||
| Konsultasi Dental GP dan Spesialis (dengan tindakan) | FREE | FREE | |
| 2 | RADIOLOGI | ||
| Rontgen Dental | 150,000 | 135,000 | |
| Rontgen Panoramic Tanpa Cetak | 300,000 | 270,000 | |
| Rontgen Panoramic Dengan Cetak | 350,000 | 315,000 | |
| Rontgen Cephalometric Tanpa Cetak | 300,000 | 270,000 | |
| Rontgen Cephalometric Dengan Cetak | 350,000 | 315,000 | |
| Paket Rontgen Panoramic & Cephalometric | 600,000 | 540,000 | |
| Rontgen TMJ Dengan Cetak | 425,000 | 382,500 | |
| 3D Dental Scanner | 1,000,000 | 900,000 | |
| Scan Gigi Clear Aligner Klar – Cobra | 100,000 | 90,000 | |
| 3 | KONSERVASI | ||
| Anestesi | 125,000 | 112,500 | |
| Open Bur / Open Akses | 350,000 | 315,000 | |
| Tambal Sementara | 250,000 | 225,000 | |
| Medikasi Intra Canal | 350,000 | 315,000 | |
| Endodontik Tunggal | 700,000 | 630,000 | |
| Retreatment Endodontik Tunggal | 750,000 | 675,000 | |
| Endodontik Ganda | 950,000 | 855,000 | |
| Retreatment Endodontik Ganda | 1,000,000 | 900,000 | |
| Root Canal Filling Tunggal | 1,025,000 | 922,500 | |
| Root Canal Filling Ganda | 1,155,000 | 1,039,500 | |
| Paket Endodontik Tunggal | 3,000,000 | 2,700,000 | |
| Paket Endodontik Tunggal dengan Mikroskop | 3,500,000 | 3,150,000 | |
| Retreatment Paket Endodontik Tunggal | 3,150,000 | 2,835,000 | |
| Retreatment Paket Endodontik Tunggal dengan Mikroskop | 3,800,000 | 3,420,000 | |
| Paket Endodontik Ganda | 3,450,000 | 3,105,000 | |
| Paket Endodontik Ganda dengan Mikroskop | 4,100,000 | 3,690,000 | |
| Retreatment Paket Endodontik Ganda | 3,700,000 | 3,330,000 | |
| Retreatment Paket Endodontik Ganda dengan Mikroskop | 4,450,000 | 4,005,000 | |
| Apeksifikasi | 575,000 | 517,500 | |
| Aplikasi Rubber Dam | 175,000 | 157,500 | |
| Desensitisasi | 250,000 | 225,000 | |
| GIC LC Base | 275,000 | 247,500 | |
| GIC LC Filling Tipe 1 | 475,000 | 427,500 | |
| GIC LC Filling Tipe 2 | 600,000 | 540,000 | |
| GIC LC Filling Tipe 3 | 650,000 | 585,000 | |
| Artificial Wall GIC/Resin | 300,000 | 270,000 | |
| Resin Komposit Tipe 1 | 475,000 | 427,500 | |
| Resin Komposit Tipe 2 | 700,000 | 630,000 | |
| Resin Komposit Tipe 3 | 800,000 | 720,000 | |
| Resin Komposit Pasca Endodonti | 950,000 | 855,000 | |
| Direct Onlay Composite | 1,750,000 | 1,575,000 | |
| Bleaching Intracoronal | 600,000 | 540,000 | |
| Bleaching In Office RARB | 4,725,000 | 4,252,500 | |
| Bleaching Home RARB | 4,000,000 | 3,600,000 | |
| Aplikasi MTA | 600,000 | 540,000 | |
| Aplikasi BioDentine | 600,000 | 540,000 | |
| Apeks Reseksi Tanpa Pengisian | 3,150,000 | 2,835,000 | |
| Apeks Reseksi Dengan MTA | 3,675,000 | 3,307,500 | |
| 4 | PERIODONTI | ||
| Scaling Kelas 1 | 475,000 | 427,500 | |
| Scaling Kelas 2 | 650,000 | 585,000 | |
| Scaling Kelas 3 | 750,000 | 675,000 | |
| Scaling Dengan Airflow | 950,000 | 855,000 | |
| Root Planing/Deep Scaling | 300,000 | 270,000 | |
| Polishing Stain | 175,000 | 157,500 | |
| Ablasi (Bleaching Gusi) RARB | 5,100,000 | 4,590,000 | |
| Ablasi (Bleaching Gusi) per Rahang | 2,650,000 | 2,385,000 | |
| Curetage | 775,000 | 697,500 | |
| Flap Operation Per Gigi | 1,850,000 | 1,665,000 | |
| Flap Operation Per Regio | 2,900,000 | 2,610,000 | |
| Occlusal Adjustment | 175,000 | 157,500 | |
| Occlusal Adjustment Per Regio | 475,000 | 427,500 | |
| Cauter | 525,000 | 472,500 | |
| Gingivektomi | 650,000 | 585,000 | |
| Gingivektomi Per Regio | 1,400,000 | 1,260,000 | |
| Splinting Dengan Wire/ Gigi | 525,000 | 472,500 | |
| Splinting Dengan Wire/ Regio | 2,600,000 | 2,340,000 | |
| Splinting Wire Tambahan | 500,000 | 450,000 | |
| Splinting Dengan Ribon / Gigi | 650,000 | 585,000 | |
| Splinting Dengan Ribon / Regio | 3,450,000 | 3,105,000 | |
| Bongkar Splinting | 175,000 | 157,500 | |
| Pedicle Graft | 4,725,000 | 4,252,500 | |
| Gingival Graft | 4,725,000 | 4,252,500 | |
| Connective Tissue Graft | 4,725,000 | 4,252,500 | |
| Tindakan Bone Graft Tipe 1 | 1,550,000 | 1,395,000 | |
| Tindakan Bone Graft Tipe 2 | 2,350,000 | 2,115,000 | |
| Tindakan Membran Tipe 1 | 1,575,000 | 1,417,500 | |
| Tindakan Membran Tipe 2 | 2,350,000 | 2,115,000 | |
| Tindakan Membran Tipe 3 | 2,625,000 | 2,362,500 | |
| Aplikasi Metronidazole | 250,000 | 225,000 | |
| Aplikasi Wound Dressing | 250,000 | 225,000 | |
| Pendalaman Vestibulum | 1,375,000 | 1,237,500 | |
| Pendalaman Vestibulum Tipe 2 | 2,100,000 | 1,890,000 | |
| Socket Preservation | 3,950,000 | 3,555,000 | |
| Hemiseksi | 3,950,000 | 3,555,000 | |
| 5 | PROSTODONTI | ||
| Konsultasi / Cetak TMJ | 450,000 | 405,000 | |
| Splint TMJ Removable | 2,310,000 | 2,079,000 | |
| Cetak Alginate | 250,000 | 225,000 | |
| Cetak Rubber Base | 300,000 | 270,000 | |
| Cetak Alginate RARB | 450,000 | 405,000 | |
| Cetak Rubber Base RARB | 600,000 | 540,000 | |
| Cetak Alginate & Rubber Base RARB | 1,000,000 | 900,000 | |
| Sementasi GIC | 525,000 | 472,500 | |
| Sementasi Resin | 600,000 | 540,000 | |
| 6 | GIGI TIRUAN LEPASAN | ||
| GTSL Acrylic (Plat + Gigi Pertama) | 2,750,000 | 2,475,000 | |
| GTSL Valplast (Plat + Gigi Pertama) | 3,325,000 | 2,992,500 | |
| GTSL FRS/Thermosen | 4,000,000 | 3,600,000 | |
| GTSLKL (Frame + Gigi Pertama) | 4,850,000 | 4,365,000 | |
| GTSKL Kombinasi FRS/Thermosen | 5,775,000 | 5,197,500 | |
| GTSLKL Kombinasi Valplast | 6,650,000 | 5,985,000 | |
| GTSLKL Kombinasi Akrilik | 6,300,000 | 5,670,000 | |
| Frame Vitallium | 4,650,000 | 4,185,000 | |
| Tambahan Gigi | 525,000 | 472,500 | |
| 7 | GELIGI TIRUAN LENGKAP | ||
| Plat Acrylic | 6,825,000 | 6,142,500 | |
| Plat Frame/Logam | 7,525,000 | 6,772,500 | |
| SCP (Sendok Cetak Perorangan) | 465,000 | 418,500 | |
| 8 | REPARASI | ||
| Tambah Elemen – Acrylic | 465,000 | 418,500 | |
| Tambah Klamer | 315,000 | 283,500 | |
| Rebasing/ Relining | 1,225,000 | 1,102,500 | |
| 9 | PIN | ||
| Customized Pin | 1,850,000 | 1,665,000 | |
| Fiber Post | 1,850,000 | 1,665,000 | |
| Fiber Post Tanpa Core | 1,050,000 | 945,000 | |
| Core Resin Tanpa Pasak | 700,000 | 630,000 | |
| Short Post per Gigi | 525,000 | 472,500 | |
| 10 | CROWN, BRIDGE, INLAY, ONLAY | ||
| Bongkar Crown Tanpa Bur | 600,000 | 540,000 | |
| Bongkar crown Dengan Bur | 925,000 | 832,500 | |
| Temporary Crown Indirect | 875,000 | 787,500 | |
| Temporary Crown Direct | 700,000 | 630,000 | |
| Crown Lengthening | 1,750,000 | 1,575,000 | |
| Crown/Inlay/Onlay/Bridge Metal | 2,900,000 | 2,610,000 | |
| Crown/Inlay/Onlay/Bridge Metal Porcelain | 4,050,000 | 3,645,000 | |
| Crown/Inlay/Onlay/Bridge Composite Resin Reinforced Zirconia (Ceramage) | 4,050,000 | 3,645,000 | |
| Crown/Inlay/Onlay/Bridge Ceramic E-Max | 4,900,000 | 4,410,000 | |
| Crown/Inlay/Onlay/Bridge Ceramic Zircon / Alumina | 5,775,000 | 5,197,500 | |
| Night Guard | 2,325,000 | 2,092,500 | |
| Kontrol Gigi Palsu (Crown/Inlay/Onlay/Bridge/Night Guard) | 300,000 | 270,000 | |
| 11 | BEDAH MULUT | ||
| Pencabutan Tanpa Komplikasi | |||
| Pencabutan Tipe 1 | 475,000 | 427,500 | |
| Pencabutan Tipe 2 | 675,000 | 607,500 | |
| Pencabutan Tipe 3 | 800,000 | 720,000 | |
| Pencabutan Dengan Komplikasi | |||
| Tipe I | 850,000 | 765,000 | |
| Tipe II | 1,025,000 | 922,500 | |
| Tipe III | 1,275,000 | 1,147,500 | |
| Odontectomy/Impaksi | |||
| Tipe 1 | 3,150,000 | 2,835,000 | |
| Tipe2 | 4,200,000 | 3,780,000 | |
| Tipe3 | 5,000,000 | 4,500,000 | |
| Operasi Mucocele | 2,900,000 | 2,610,000 | |
| Frenectomy | 2,325,000 | 2,092,500 | |
| Coronectomy | 3,150,000 | 2,835,000 | |
| Operculectomy | 525,000 | 472,500 | |
| Insisi/Eksisi | 575,000 | 517,500 | |
| Apeks Reseksi Tanpa Pengisian | 3,150,000 | 2,835,000 | |
| Apeks Reseksi Dengan MTA | 3,675,000 | 3,307,500 | |
| Aplikasi MTA | 600,000 | 540,000 | |
| Aplikasi BioDentine | 600,000 | 540,000 | |
| Dry Socket | 375,000 | 337,500 | |
| Hecting (Tindakan Jahit) < 5 | 210,000 | 189,000 | |
| Hecting (Tindakan Jahit) 5-10 | 265,000 | 238,500 | |
| Kontrol Buka Jahitan | 235,000 | 211,500 | |
| Kontrol Buka Jahitan OD | 345,000 | 310,500 | |
| Paket Bedah Sinus Lifting | 9,850,000 | 8,865,000 | |
| Reposisi Dislokasi TMJ | 1,200,000 | 1,080,000 | |
| Paket Bedah Ridge Split | 9,000,000 | 8,100,000 | |
| Windowing | 2,850,000 | 2,565,000 | |
| 12 | ORTHODONTI | ||
| Fixed : | |||
| Orthodonti – Metal/RARB | 13,000,000 | 11,700,000 | |
| Orthodonti – Damon Metal RARB | 28,000,000 | 25,200,000 | |
| Orthodonti – Damon Clear RARB | 29,500,000 | 26,550,000 | |
| Orthodonti – Self Ligating Brace RARB | 19,000,000 | 17,100,000 | |
| Orthodonti – Clear Aligner Klar Basic | 19,000,000 | 17,100,000 | |
| Orthodonti – Aligner Klar Advance | 25,000,000 | 22,500,000 | |
| Orthodonti – Aligner Klar Pro | 33,500,000 | 30,150,000 | |
| Orthodonti – Aligner Klar Kids | 8,500,000 | 7,650,000 | |
| Orthodonti – Aligner Klar Kids Plus | 19,000,000 | 17,100,000 | |
| Orthodonti – Aligner Invisalign Basic | 69,000,000 | 62,100,000 | |
| Orthodonti – Aligner Invisalign Intermediate | 79,000,000 | 71,100,000 | |
| Orthodonti – Aligner Invisalign Advance | 90,000,000 | 81,000,000 | |
| 2 X 4 Orthodonti Appliance | 5,250,000 | 4,725,000 | |
| Biaya Pindah Dokter – Metal | 4,200,000 | 3,780,000 | |
| Biaya Pindah Dokter – Damon | 6,300,000 | 5,670,000 | |
| Retainer Fix | 2,550,000 | 2,295,000 | |
| Retainer Lepasan | 1,900,000 | 1,710,000 | |
| Essix Retainer | 1,900,000 | 1,710,000 | |
| Aktivator | 3,700,000 | 3,330,000 | |
| LM Activator | 4,750,000 | 4,275,000 | |
| Lip Bumper | 1,750,000 | 1,575,000 | |
| Replacement Braces Metal | 195,000 | 175,500 | |
| Replacement Braces Damon Metal | 850,000 | 765,000 | |
| Replacement Braces Damon Clear | 1,025,000 | 922,500 | |
| Orthodonti – Kontrol Metal 1 & Myobrace | 400,000 | 360,000 | |
| Orthodonti – Kontrol Metal 2 | 475,000 | 427,500 | |
| Orthodonti – Kontrol Damon | 525,000 | 472,500 | |
| RPE Orthodontic Appliance | 4,600,000 | 4,140,000 | |
| Face Mask Orthodontic Appliance | 5,775,000 | 5,197,500 | |
| Peninggi Gigitan GIC | 105,000 | 94,500 | |
| Peninggi Gigitan Resin Komposit | 315,000 | 283,500 | |
| Alat tambahan : | |||
| Forsus CS 5 | 4,050,000 | 3,645,000 | |
| Palatal Rib | 2,550,000 | 2,295,000 | |
| Lingual/Palatal Arch | 2,550,000 | 2,295,000 | |
| Rapid Palatal Expander | 2,650,000 | 2,385,000 | |
| Ring | 450,000 | 405,000 | |
| Buccal Tube | 200,000 | 180,000 | |
| Buccal Tube 2 | – | – | |
| Molar Band | 325,000 | 292,500 | |
| Debonding | 875,000 | 787,500 | |
| Rebonding | – | – | |
| Resementasi Band Ortho Lepas | 120,000 | 108,000 | |
| Button | 200,000 | 180,000 | |
| Elastic | 60,000 | 54,000 | |
| Lem Bracket | 60,000 | 54,000 | |
| Drop in Hook | 195,000 | 175,500 | |
| 13 | IMPLANT | ||
| NTI (Include Crown PFM) | 31,500,000 | 28,350,000 | |
| Dentium (Include Crown PFM) | 19,000,000 | 17,100,000 | |
| Ortho Implant Miniscrew | 2,350,000 | 2,115,000 | |
| 14 | PEDODONTI | ||
| Konsultasi + DHE | 350,000 | 315,000 | |
| Konsultasi Spesialis + DHE | 375,000 | 337,500 | |
| First Dental Visit A | 375,000 | 337,500 | |
| First Dental Visit B | 400,000 | 360,000 | |
| Oral Profilaksis Pedo Dengan Perawatan Lain | 175,000 | 157,500 | |
| Oral Profilaksis Pedo | 350,000 | 315,000 | |
| Scaling and Polishing Pedo Tipe 1 | 425,000 | 382,500 | |
| Scaling and Polishing Pedo Tipe 2 | 600,000 | 540,000 | |
| Topical Application Fluoride | 400,000 | 360,000 | |
| Pit & Fissure Sealant GIC – Pedo | 425,000 | 382,500 | |
| Pit & Fissure Sealant Komposit – Pedo | 475,000 | 427,500 | |
| GIC Filling Pedo Tipe 1 | 450,000 | 405,000 | |
| GIC Filling Pedo Tipe 2 | 575,000 | 517,500 | |
| GIC Filling Pedo Tipe 3 | 650,000 | 585,000 | |
| Compomer Pedo Tipe 1 | 475,000 | 427,500 | |
| Compomer Pedo Tipe 2 | 625,000 | 562,500 | |
| Compomer Pedo Tipe 3 | 700,000 | 630,000 | |
| Resin Komposit Pedo Anterior Tipe 1 | 525,000 | 472,500 | |
| Resin Komposit Pedo Anterior Tipe 2 | 650,000 | 585,000 | |
| Resin Komposit Pedo Posterior | 650,000 | 585,000 | |
| Metal / Stainless Steel Crown Pedo | 1,200,000 | 1,080,000 | |
| Compomer Pedo Complex | 1,000,000 | 900,000 | |
| Compomer Pedo Complex Multiple | 850,000 | 765,000 | |
| Hybrid Resin Complex | 1,550,000 | 1,395,000 | |
| Sementasi Pedo | 250,000 | 225,000 | |
| Resementasi SSC Pedo | 275,000 | 247,500 | |
| Pulp Capping Pedo | 400,000 | 360,000 | |
| Pulpotomi Gigi Sulung Anterior | 700,000 | 630,000 | |
| Pulpotomi Gigi Sulung Posterior | 800,000 | 720,000 | |
| Endodontik Gigi Sulung Anterior/Kunjungan | 750,000 | 675,000 | |
| Endodontik Gigi Sulung Posterior/Kunjungan | 850,000 | 765,000 | |
| One Visit Endodontik Gigi Sulung Anterior | 925,000 | 832,500 | |
| One Visit Endodontik Gigi Sulung Posterior | 1,025,000 | 922,500 | |
| Ekstraksi Gigi Sulung Dengan Topikal Anestesi | 425,000 | 382,500 | |
| Ekstraksi Gigi Sulung Dengan Anestesi Injeksi | 650,000 | 585,000 | |
| Ekstraksi Gigi Sulung Komplikasi | 750,000 | 675,000 | |
| Insisi Abses Pedo | 350,000 | 315,000 | |
| Space Maintainer Removable 1 | 1,750,000 | 1,575,000 | |
| Space Maintainer Removable 2 | 2,800,000 | 2,520,000 | |
| Space Maintainer Fix 1 | 1,750,000 | 1,575,000 | |
| Space Maintainer Fix 2 | 2,800,000 | 2,520,000 | |
| Removable Appliance 1 Rahang | 2,625,000 | 2,362,500 | |
| Removable Appliance 2 Rahang | 5,000,000 | 4,500,000 | |
| Inclined Bite Plane | 1,750,000 | 1,575,000 | |
| Kontrol Removable Appliance Pedo | 350,000 | 315,000 | |
| Functional Appliance (Twin Blok, Bionator) | 3,675,000 | 3,307,500 | |
| Myo Pack 1 | 2,800,000 | 2,520,000 | |
| Myo Pack 2 | 4,375,000 | 3,937,500 | |
| T4K / Myobrace | 1,900,000 | 1,710,000 | |
| Behavioural Management Ringan | 250,000 | 225,000 | |
| Behavioural Management Sedang | 300,000 | 270,000 | |
| Behavioural Management Berat | 350,000 | 315,000 | |
| 16 | DENTAL ESTETIK | ||
| Direct Veneer Dengan Resin Komposit | 1,450,000 | 1,305,000 | |
| Indirect Veneer Dengan Ceramic (E-Max) | 5,375,000 | 4,837,500 | |
| Indirect Veneer Dengan Ceramic (Zircon) | 6,300,000 | 5,670,000 | |
| Tooth Jewelry | 925,000 | – |
