GQE-120117-48482670e5

1 Dec 2017
# 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

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