GQE-120117-16e89ddf60

1 Dec 2017
# Item Codes and Description Quantity Price
1 Service 1  –  [For Tooth Number(s): (17)]
  • d-011: Comprehensive oral examination
  • d-013: Oral examination – limited
  • d-015: Consultation – extended
1x(180.00)
  • 1x(57.00)
  • 1x(39.00)
  • 1x(84.00)
180.00
2 Procedure 1
  • d-012: Periodic oral examination
  • d-014: Consultation
  • d-015: Consultation – extended
1x(185.00)
  • 1x(47.00)
  • 1x(54.00)
  • 1x(84.00)
185.00
3 d-016
  • d-016: Consultation by referral
1x(96.00)
  • 1x(96.00)
96.00
Sub Total (A): 461.00
Cover Payout (D): 376.60
Gap Total (Est.): (C – D) 84.40

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