#	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