#	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