GQE-120117-5e713ad5f7

1 Dec 2017
# 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

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