GQE-111817-97f3947c63

18 Nov 2017
# Item Codes and Description Quantity Price
1 Service 1  –  [For Tooth Number(s): (14,17)]
  • 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): (18,38)]
  • s-001:
2x(15.00)
  • 2x(15.00)
30.00
Sub Total (A): 75.00
Cover Payout (D): 45.00
Gap Total (Est.): (C – D) 30.00

Search

+