#	Item Codes and Description	Quantity	Price
1	Service 1  –  [For Tooth Number(s): (25)] 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
	Sub Total (A):		180.00
	Cover Payout (D):		0.00
	Gap Total (Est.):	(C – D)	180.00