#	Item Codes and Description	Quantity	Price
1	Service 1  –  [For Tooth Number(s): (33,43)] d-011: Comprehensive oral examination d-013: Oral examination – limited d-015: Consultation – extended	2x(81.50) 2x(53.55) 2x(27.95) 2x(0.00)	163.00
2	d-019 d-019: Letter of referral	1x(11.30) 1x(11.30)	11.30
3	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
	Sub Total (A):		218.80
	Cover Payout (D):		153.16
	Gap Total (Est.):	(C – D)	65.64