#	Item Codes and Description	Quantity	Price
1	Demo Service  –  [For Tooth Number(s): (12,18,28,47)] s-001: d-0001:	4x(130.00) 4x(15.00) 4x(115.00)	520.00
2	Service 1  –  [For Tooth Number(s): (17,22,28,47)] s-001:	4x(15.00) 4x(15.00)	60.00
3	Demo Service  –  [For Tooth Number(s): (11,16)] s-001: d-0001:	2x(130.00) 2x(15.00) 2x(115.00)	260.00
4	Demo Procedure  –  [For Tooth Number(s): (12,28)] d-0001:	2x(115.00) 2x(115.00)	230.00
5	Procedure 1 s-001:	1x(15.00) 1x(15.00)	15.00
6	s-001  –  [For Tooth Number(s): (18,47)] s-001:	2x(15.00) 2x(15.00)	30.00
7	d-0001  –  [For Tooth Number(s): (16,26)] d-0001:	2x(115.00) 2x(115.00)	230.00
	Sub Total (A):		1,345.00
	Discount Total (B):	(percentage) : 5.00	67.25
	Gross Total (C):	(A – B)	1,277.75
	Cover Payout (D):		1,249.97
	Gap Total (Est.):	(C – D)	27.78