GQE-120117-25cb91433a

1 Dec 2017
# Item Codes and Description Quantity Price
1 Service 1  –  [For Tooth Number(s): (34,36)]
  • d-011: Comprehensive oral examination
  • d-013: Oral examination – limited
  • d-015: Consultation – extended
2x(80.15)
  • 2x(52.65)
  • 2x(27.50)
  • 2x(0.00)
160.30
2 Procedure 1
  • d-012: Periodic oral examination
  • d-014: Consultation
  • d-015: Consultation – extended
1x(43.75)
  • 1x(43.75)
  • 1x(0.00)
  • 1x(0.00)
43.75
3 d-019
  • d-019: Letter of referral
1x(0.00)
  • 1x(0.00)
0.00
Sub Total (A): 204.05
Cover Payout (D): 122.43
Gap Total (Est.): (C – D) 81.62

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