GQE-120117-553008359d

1 Dec 2017
# Item Codes and Description Quantity Price
1 Service 1  –  [For Tooth Number(s): (16)]
  • d-011: Comprehensive oral examination
  • d-013: Oral examination – limited
  • d-015: Consultation – extended
1x(81.50)
  • 1x(53.55)
  • 1x(27.95)
  • 1x(0.00)
81.50
2 Procedure 1
  • d-012: Periodic oral examination
  • d-014: Consultation
  • d-015: Consultation – extended
1x(44.50)
  • 1x(44.50)
  • 1x(0.00)
  • 1x(0.00)
44.50
3 d-011
  • d-011: Comprehensive oral examination
1x(53.55)
  • 1x(53.55)
53.55
Sub Total (A): 179.55
Cover Payout (D): 161.60
Gap Total (Est.): (C – D) 17.95

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