GQE-111717-bc2dba00ea

17 Nov 2017
# Item Codes and Description Quantity Price
1 Service 1  –  [For Tooth Number(s): (14,18)]
  • s-001:
2x(15.00)
  • 2x(15.00)
30.00
2 Procedure 1
  • s-001:
1x(15.00)
  • 1x(15.00)
15.00
3 s-001  –  [For Tooth Number(s): (21,38)]
  • s-001:
2x(15.00)
  • 2x(15.00)
30.00
Sub Total (A): 75.00
Cover Payout (D): 52.50
Gap Total (Est.): (C – D) 22.50

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