#	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